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GoMococci  IN  Pus. 
stained  by — 1,  Knaack's  method.     2,  N'eisser's  double  stain.     3,  Lanz's  method. 
4,  Loffler'a  methylene-blue.     5.  Romanowsky'.s  stain  (Leishman'a  modi6cation).     6,  Leszczyn- 
sky's  method. 


GONORRHEA  IN  WOMEN 


ITS  PATHOLOGY,  SYMPTOMATOLOGY,  DIAGNOSIS,  AND 

TREATMENT;    TOGETHER  WITH   A   REVIEW   OF 

THE   RARE   VARIETIES  OF  THE   DISEASE 

WHICH  OCCUR  IN  MEN,  WOMEN 

AND  CHILDREN 


CHARLES  C.  NORRIS,  M.D. 

IK 

INSTRUCTOR    IN    GYNECOLOGY,  UNIVERSITY   OF    PENNSYLVANIA:     ASSISTANT    GYNECOLOGIST 


WITH   AN   INTRODl'CTION   BV 

JOHN  G.   CLARK,  M.D. 

;      OVNECOLOGIST-IN-CHIEF   TO 


ILLCSTRATED  BY 
DOROTHY    PEIERS 


PHI1..AI)EI.PHIA    ANU    LONDON' 

W.  B.  SAUNDERS  COMPANY 

1913 


^3-^T<^b'^ 


Copyright,  1913,  by  W.  B.  Saunders  Company 


PRINTED  IN  AMERICA 


RESPECTFULLY  DEDICATED  TO 
MY  TEACHER 

3iol)n  <3.  Clarfe 


INTRODUCTORY 

In  this  exceedingly  comprehensive  volume  on  gonorrhea  Dr. 
Norris  has  placed  before  us,  in  a  most  interesting  and  instructive  way, 
the  many  phases  of  this  subject.  The  historic  narrative,  which  leads 
back  to  the  earliest  records  of  the  disease,  is  intensely  entertaining, 
following  as  it  does  the  curious  and  bizarre  views  expressed  in  ancient 
literature  regarding  the  affection  up  to  the  description  of  the  remark- 
able experiment  performed  by  Hunter  upon  himself,  in  which  he  en- 
deavored to  show  that  the  specific  virus  of  gonorrhea  and  that  of 
syphilis  were  interchangeable.  As  a  result  of  this  remarkable  but 
fallacious  experiment  Hunter's  theory  of  the  mutual  identity  of  the 
two  infections  was  accepted  by  the  profession  without  further  question. 
In  spite  of  the  later  and  well-sustained  dissent  by  Ricord,  this  view  con- 
tinued to  hold  sway,  and  was  not  entirely  dissipated  until  the  dis- 
covery, by  Neisser,  of  the  specific  microorganism  of  gonorrhea.  This 
discovery  put  an  end  to  the  long-agitated  discussion,  and  for  the 
first  time  a  scientific  foundation  was  established  upon  which  all  mod- 
ern work  along  this  line  has  been  constructed. 

One  learns  from  the  ancient  documents,  as  set  down  by  Dr.  Norris, 
that  the  ravages  of  gonorrhea  were  recognized,  and  that  strenuous 
efforts  were  made,  by  segregation  and  other  restrictive  means,  to 
limit  its  spread. 

In  the  chapter  on  Bacteriology  and  the  Pathogenesis  of  Gonorrhea, 
the  author  has  very  clearly  described  the  best  cultural  and  staining 
methods,  and  traced  the  destructive  efTects  of  the  gonococcus  upon  the 
pelvic  organs  and  other  tissues  of  the  body.  This  study  is  elaborately 
illustrated  from  gross  and  microscopic  sections  made  by  Dr.  Norris 
from  the  extensive  collection  in  the  pathologic  laboratory  of  the  Gyne- 
cologic Department  of  the  University  of  Pennsylvania.  The  litera- 
ture has  been  carefully  compiled,  and  has  been  so  well  digested  as  to 
furnish  an  almost  encyclopedic  review  of  all  the  various  aspects  and 
history  of  the  Neisserian  infection. 

In  the  chapter  on  Sociology  the  author  has  considered  the  relation- 
ship of  gonorrhea  to  sterility  and  abortion,  and  has  shown  the  havoc 
that  is  wrought  in  the  destruction  of  the  eye-sight  of  new-born  infants 
as  the  result  of  maternal  infection.  Statistics  have  been  carefully 
compiled  demonstrating  the  serious  efTects  of  this  disease  upon  the 


6  INTRODUCTORY 

given  individual,  and,  more  especially,  its  pernicious  influence  upon 
the  general  civic  body. 

The  various  methods  adopted  by  the  governments  of  Europe  and 
the  Orient  for  the  limitation  and  suppression  of  the  social  evil  have 
been  reviewed,  and  the  situation  as  it  exists  in  the  United  States  has 
been  very  thoroughly  dealt  with.  Arguments  for  and  against  muni- 
cipal supervision  of  prostitution  are  presented,  and  the  author  accepts 
the  conclusion,  reached  by  the  majority  of  physicians  and  a  large  body 
of  social  workers,  that  legal  restraint  is  of  little  actual  value  in  the 
curtailment  or  abrogation  of  this  evil. 

Under  the  head  of  Prophylaxis  the  methods  of  preventing  the  spread 
of  the  disease  are  presented.  Special  stress  is  laid  upon  the  necessity 
for  educating  patients  as  to  the  communicability  of  this  malady,  and 
for  protecting  innocent  individuals  against  its  serious  immediate  and 
remote  effects.  The  author  insists  upon  the  necessity  for  an  obliga- 
tory certificate  of  health  for  the  male  before  marriage  should  be  per- 
mitted. He  condemns  the  policy  of  rigid  secrecy  relative  to  venereal 
diseases  that  now  prevails,  and  lays  particular  stress  upon  the  ad- 
vantage to  be  gained  by  making  these  diseases  notifiable.  In  other 
words,  the  author  would  have  gonorrhea  treated  like  all  other  dis- 
eases that,  through  their  contagiousness,  threaten  the  general  public. 
Individuals  so  affected  should,  therefore,  he  maintains,  be  segregated 
in  special  hospitals  or  kept  under  rigid  observation  until  a  cure  has 
been  effected. 

A  full  description  of  the  approved  methods  of  examination  and  of 
the  means  for  ascertaining  with  certainty  the  presence  of  the  gono- 
coccus  is  given  in  a  separate  chapter.  The  necessity  for  ascertaining 
when  a  cure  has  been  efTected  has  been  dwelt  upon.  The  author 
deplores  the  light  and  careless  manner  in  which  gonorrhea  has  been 
treated  in  the  past,  and  considers  the  profession  partially  responsible 
for  the  spread  of  this  disease.  He  regards  as  criminal  laxity  the 
neglect  of  physicians  to  determine  that  an  actual  cure  has  been  effected 
before  an  infected  individual  is  permitted  to  marry. 

In  tracing  the  pathologic  changes  incident  to  this  infection,  a 
topographic  sequence  has  been  adopted,  beginning  first  with  the  ex- 
ternal genitalia  and  following  the  process  through  the  generative  tract 
to  the  ovaries  and  tubes. 

A  subsequent  chapter  is  devoted  to  a  comprehensive  description  of 
operative  methods  of  treatment,  and  special  attention  is  directed  to 
the  necessity  for  instituting  conservative  medical  treatment  before 
surgical  intervention  is  undertaken.  Thus  the  surgeon  endeavors  to 
subdue  the  inflammation,  and  later,  if  necessity  arises,  removes,  by 


INTRODUCTORY  i 

surgical  means,  anj'  pathologic  residuum  or  debris  that  may  remain 
after  the  gonococcal  storm  has  passed,  conserving  those  organs  or 
portions  of  tissue  that  still  have  functional  value,  rather  than  sacri- 
ficing the  pelvic  generative  organs  in  toto.  This  conservative  policy 
should  be  applied  particularly  to  young  individuals,  in  whom  this 
infection  so  frequently  occurs. 

A  chapter  has  been  devoted  to  the  consideration  of  Diffuse  Gon- 
orrheal Peritonitis,  a  subject  that  is  comparatively  little  understood 
by  physicians  and  surgeons,  because  of  its  infrecjuent  occurrence,  the 
infection  usualh'  expending  its  virulence  upon  the  adnexa  and  the  pelvic 
peritoneum  and  rarely  spreading  to  the  upper  abdomen. 

An  important  chapter  is  that  dealing  with  Gonorrhea  During  Preg- 
nane}', Parturition,  and  the  Puerperium.  In  maternity  cases  it  is 
especialh'  important  for  pM-.sicians  and  attendants  to  be  ever  on  the 
alert,  first,  to  prevent  the  spread  of  the  disease  in  the  mother,  and, 
secondly,  to  give  the  most  minute  attention  to  the  new-born  child,  to 
protect  it  against  the  life-long  misery  that  may  come  from  ophthalmia 
neonatorum. 

The  final  chapter  deals  exhaustively  with  the  medicinal  treatment 
f)f  gonorrhea.  The  various  clinical  methods  for  the  detection  of  the 
infection  and  a  comparative  study  of  the  results  of  treatment  are 
given  in  comprehensive  detail,-  with  a  final  summarj',  bj'  the  author, 
of  what  he  considers  to  be  the  proper  therapeutic  care  of  these  patients. 
The  relative  value  and  the  present  status  of  the  serum  and  vaccine 
treatments  are  considered  in  this  chapter.  An  extensive  bibliography, 
from  which  the  author  has  selected  a  vast  amount  of  splendid  material, 
citing  innumerable  articles  to  which  one  may  turn  to  consult  these 
original  sources,  completes  the  book. 

The  careful  student  will  find,  after  a  close  perusal  of  the  work,  that 
the  author  has  written  a  highly  instructive  treatise,  in  which  he  has 
most  satisfactorily  encompassed  the  many  aspects  of  this  complicated 
cjuestion.  He  has  reviewed  in  detail  the  several  divergent  sociologic 
\iows  concerning  this  collosal  evil,  and,  as  a  commentary,  offers 
,iu<licious  suggestions  that  will  be  of  value  to  those  who  are  endeavoring 
to  find  the  best  solution  for  these  problems.  Because  of  the  broad  and 
comprehensive  character  of  the  I)ook,  it  will  be  of  great  value  to  the 
physician,  tlic  surgeon,  the  specialist,  the  legishitor,  and  tiic  sociologist. 

John  Ci.  C'l.\kk. 


PREFACE 

Until  a  comparatively  recent  date  gonorrhea  has  been  regarded 
by  many  medical  men  as  a  purely  local  disease,  and  it  is  only  during 
the  last  twelve  or  fifteen  years  that  the  rare  lesions  resulting  from  this 
infection  have  been  traced  to  their  proper  source.  Indeed,  prior  to 
the  appearance  of  Noeggerath's  epoch-making  monograph  even  the 
common  intraperitoneal  manifestations  of  gonorrhea  were  not  recog- 
nized. Up  to  this  time  practically  all  pelvic  inflammations  were  re- 
garded as  cellulitis,  and  their  etiologic  relationship  to  gonorrhea  was 
not  generally  known,  although  Goupil  and  Bernutz  had  described 
the  pathology  as  early  as  1862.  The  discovery  of  the  gonococcus  by 
Neisser  in  1879  placed  the  study  of  gonorrhea  upon  a  scientific 
basis,  and  within  recent  years  the  symptomatology  and  pathology 
that  follow  in  the  wake  of  this  infection  have  received  marked 
attention. 

In  the  preparation  of  a  work  such  as  this  one  of  the  chief  difficulties 
consists  in  selecting  the  important  and  omitting  the  unimportant 
references  to  the  ^'arious  subjects  dealt  with.  This  difficulty  will  be 
apparent  when  it  is  considered  that  during  the  last  ten  years  over 
20,000  papers  bearing  more  or  less  directly  upon  the  subject  of  gon- 
orrhea have  appeared.  From  this  voluminous  material  over  2300 
references  have  been  utilized,  and  even  in  this  moderately  extensive 
list  it  is  likely  that  some  important  publications  have  been  over- 
looked. The  chapter  on  Serum  and  Vaccine  Therapy  and  Organo- 
therapy is  based  largely  on  the  work  of  other  investigators.  For  the 
indications  and  technicof  this  form  of  treatment  the  reader  is  referred 
to  the  special  chapter  devoted  to  this  subject.  Chapters  XI  and  XII, 
the  substance  of  which  appeared  in  Surgery,  Gynecology,  and  Obstet- 
rics, October,  1910,  and  which  was  written  in  collaboration  with  Dr. 
John  G.  Clark,  have  l^een  extensively  revised  and  brought  up  to  date. 

In  the  selection  of  the  literature  an  endeavor  has  been  made  to 
utilize  only  such  material  as  embodies  the  most  modern  trend  of  science 
or  that  refers  to  rare  cases.  The  attempt  has  been  made  to  incorporate 
either  references  to  or  abstracts  from  the  reported  histories  of  all 
unusual  gonorrheal  lesions.  Thus,  under  this  head  will  be  found  a 
short  abstract  of  all  cases  of  rupture  or  torsion  of  the  uterine  adnexa  in 
inflannnatory  conditions,  of  all  gonorrheal  lesions  of  (he  i)l('ura  and 


10  ■  PREFACE 

kidney,  etc.  The  not  infrequent  practice  of  reporting  rare  cases 
under  misleading  or  ambiguous  titles  is  especially  to  be  deprecated, 
and  makes  the  complete  list  of  such  cases  practically  impossible  to 
obtain. 

I  wish  to  acknowledge  my  indebtedness  to  the  excellent  papers  of 
Finger  and  Spooner,  which  have  been  extensively  drawn  ujion  in  com- 
piling the  chapter  on  the  History  of  Gonorrhea.  Stephenson's  mas- 
terly monograph  on  ophthalmia  neonatorum  has  been  freely  utilized 
in  the  chapter  on  eye  lesions.  Nixon's  important  article  on  renal 
gonorrhea,  and  Menge's  monograph  on  gonorrhea  in  women,  have  also 
been  found  of  great  assistance,  as  well  as  many  other  valuable  contribu- 
tions too  numerous  to  mention,  the  references  to  which  can  be  found 
in  the  foot-notes. 

In  the  preparation  of  this  work  I  have  received  the  most  hearty 
support  and  encouragement  from  Dr.  John  G.  Clark,  who  has  placed 
at  my  disposal  his  abundant  clinical  and  pathologic  material.  It 
gives  me  much  pleasure  to  acknowledge  my  indebtedness  to  Dr. 
Thomas  B.  Hollo  way,  who  has  kindly  reviewed  the  chapter  dealing 
with  eye  lesions  and  has  made  many  valuable  suggestions.  My  thanks 
are  also  due  to  Dr.  George  W.  Outerbridge  for  reading  the  chapter 
on  the  Patholog.y  of  the  Female  Genital  Tract,  to  Miss  Dorothy 
Peters,  for  the  excellent  illustrations,  and  to  the  W.  B.  Saunders  Com- 
pany, for  much  practical  aid  and  for  painstaking  efforts  to  obtain 
the  best  possible  reproductions  of  the  drawings. 

Charles  C.  Norris. 

1.503  Locust  Street,  Philadelphl\,  Pa.,  May,  1913. 


CONTENTS 


CHAPTER  I  PAGE 

Historic 17 

CHAPTER  II 
Bacteriology  of  the  Goxococcrs 44 

CHAPTER  III 

Pathologic  Changes  Produced  by  the  Gonococcus  in  the  Fe\l\le  Genital  Tract  87 

Vulvitis 89 

Inflammatory  Lesions  of  Bartholin's  Gland 89 

Condylomata  Acuminata 93 

Vaginitis 93 

Urethritis 95 

Cervicitis 96 

Corporeal  Endometritis  and  Metritis .  .' 98 

Salpingitis 105 

Oophoritis   -. 114 

CHAPTER  IV 

Pathogenesis 117 

CHAPTER  V 
Sociology 126 

CHAPTER  VI 

I'kostitution 149 

CHAPTER  VII 
Prophylaxis — -Method  of  Dealing  with  G()N(jrrheics  to  Prevent  the  Spread  op 

THE  Disease 164 

CHAPTER  Mil 
'I'mk  Examination  of  1'atients 183 

('IIAI'T1;K   1.\ 

Gonorrhea  of  the  External  IIenitalia 195 

Vulvitis 195 

Condylomata  Acuminata 198 

Bartholinitis 201 

Cyst  of  Bartholin's  Gland 203 

Abscess  of  Bartholin's  C !land 204 

Urethritis "205 

11 


12  CONTENTS 

CHAPTER  X 

Gonorrheal  Vaginitis  and  Cervicitis 213 

Vaginitis 213 

Vaginal  Condylomata 222 

Cer\'icitis 222 

Pruritus  Vulva> 230 

Condylomata  of  the  Cervix 231 

CHAPTER  XI 

Gonorrheal  Endometritis,  Metritis,  and  Intramural  Uterine  Abscess 232 

Endometritis 232 

Acute  Endometritis 234 

Chronic  Endometritis 237 

Adenomyoma  of  the  Uterus  with  Chronic  Endometritis 245 

Metritis 246 

Acute  Metritis 246 

Chronic  Metritis 248 

Intramural  Abscess  of  the  Uterus 252 

CHAPTER  XII 

Gonorrhea  of  the  Fallopian  Tubes  and  Ovaries 259 

Acute  Pelvic  Inflammatory  Disease 263 

Clu'onic  Pelvic  Inflammatory  Disease 265 

CHAPTER  XIII 

The  Treatment  of  Pelvic   Inflammatory  Disease 274 

The  Time  to  Operate  on  Cases  of  Pelvic  Peritonitis 284 

Conservative  Surgery  of  the  Uterus  and  Appendages  in  Cases  of  Gonococcal  Pelvic 

Peritonitis 285 

Conservative  Surgery  of  the  Fallopian  Tubes 285 

Conservative  Ovarita  Surgery 287 

Salpingectomy.     Ovarian  Conservation  and  Suspension  of  the  Uterus 290 

Ovarian  Conservation  after  Hysterectomy 299 

Conservative  Uterine  Surgery 300 

The  Condition  of  the  Vermiform  Appendix  in  Cases  of  Pelvic  Peritonitis 301 

Immediate  Mortality  of  Conservative  Surgery 302 

End-Results  of  Conservative  Surgery 303 

Pregnancies  Resulting  after  Conservative  Surgery 305 

Possibilities  of  Ectopic  Pregnancy  Following  Conservative  Operations 307 

Proportion  of  Cases  Requiring  a  Secondary  Operation  after  a  Conservative  Opera- 
tion    307 

Conclusions 308 

Hysterectomy   and   Bilateral   Salpingo-oophorectomy   for   Pelvic   Inflammatory 

Disease 311 

Drainage  in  Cases  of  Pelvic  Inflammatory  Disease 314 

Corpus  Luteum  Organotherapy  for  the  Artificial  Menopause 316 

Post-operative  Care  of  Cases  of  Pelvic  Inflammatory  Disease 318 

CHAPTER  XIV 
Unusual  Manifestations  and  Remote  Complications  op  Pelvic  Inflammatory 

Disease 319 

Rupture  of  Inflammatory  Uterine  Adnexa  into  the  Peritoneal  Cavity 319 

Torsion  of  Inflamed  Uterine  Adnexa 339 


CONTENTS  13 


Diffuse  Peritonitis 355 

Hydrops  Tubse  Profluens 360 

Infection  of  Intrapelvie  Neoplasms 361 

Mixed  Infection 362 

Gonorrhea  as  the  Etiologic  Factor  in  the  Causation  of  Ectopic  Pregnancy 363 

Gonorrhea  as  a  Predisposing  Factor  to  Carcinoma 363 

Herniated  Inflammatory  Adnexa 364 

Esthiomene  and  Elephantiasis 364 

CHAPTER  XV 

Gonorrhea  in  Pregnancy,  Labor.  ant>  the  Puerperium 366 

Puerperal  Infection 368 

CHAPTER  XVI 

Gonorrhea  in  the  Extremes  of  Life 376 

Gonorrhea  in  Children 376 

Gonorrhea  in  the  Aged 387 

CHAPTER  XVII 

Complications  ant)  NoN-GE^^TAL  Gonorrhea. — Cystitis. — Adenitis. — Proctitis. 
— Stomatitis. — Rhinitis. — Ophthalmia  in  Infants,  Young  Girl.s,   antj 

j\j>nLTS • 390 

Cystitis 390 

Lymphadenitis 394 

Proctitis , 395 

Stomatitis 398 

Rhinitis 401 

Ophthalmia  Neonatorum   402 

Conjunctivitis  in  the  Adult 413 

CHAPTER  XVIII 
Gonorrheal  Septicemia,  Bacteremia,  and  Toxemia. — Gonorrhea  of  the  Osseous 

AKD    CiRCUL.\TORY   SYSTEMS 418 

Septicemia,  Bacteremia,  and  Toxemia 418 

Bone  and  Joint  Lesions  Produced  by  Gonorrhea 425 

Tenosynovitis 433 

Osteoperiostitis 433 

Perichondritis  and  Chondritis 435 

Cardiac  Lesions 436 

Endocarditis 436 

Pericarditis 438 

Myocarditis 439 

Aortitis 439 

Phlebitis 439 

Thrombosis 441 

CHAPTER  XIX 
Gonorrheal  Skin  Lesions. — Gonorrhea  of  the  Lungs,  Pleura,  Kidneys,  and 
Nervous    System. — Parotiditis. — Otitis. — Suppurative    Myositis    and 

Subcutaneous  Abscess. — Wound  Infection 442 

Skin  Lesions 442 

Gonorrhea  of  the  Lungs 449 


14  CONTENTS 

PAGE 

Pleurisy 450 

Gonorrhea  of  the  Kidney 452 

Perinephritis 461 

Gonorrhea  of  tlie  Nervous  System 461 

Parotiditis 465 

Otitis 465 

Suppurative  Myositis  and  Subcutaneous  Abscess  of  Gonorrheal  Origin 465 

Wound  Infection 467 

CHAPTER  XX 

Gonorrheal  Therapy 469 

Drugs  Employed  in  the  Local  Treatment  of  Gonorrhea 469 

Serum  and  Vaccine  Therapy  for  Gonorrhea 486 

Vaccines 493 


Index  of  Names 497 

Index 511 


LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

1.  Method  of  Reduplipution  of  the  Gonococci 45 

2.  EiKlocervicitis  ....'. facing     96 

3.  Endometrium  During  the  Postmenstrual  Period facing    98 

4.  Endometrium  During  the  Interval facing     98 

5.  Endometrium  During  the  Premenstrual  Stage facing    99 

6.  The  Decidua  of  Intra-uterine  Pregnancy facing  100 

7.  Glandular  Epithelium  During  the  Postmenstrual  Stage facing  101 

8.  Glandular  Epithelium  During  the  Interval facing  101 

9.  Glandular  Epithelium  During  the  Late  Premenstrual  Stage facing  101 

10.  Typical  Opitz-Gebhard  Glands,  Showing  Fern-like  Ingrowths  of  Proliferating  Epi- 

thehum facing  102 

1 1 .  Stroma  Cells facing  102 

12.  Hypertrophy  of  the  Cervix,  Chronic  Endometritis,  Chronic  Metritis,  and  Bilateral 

Adnexitis facing  104 

13.  Endometritis  and  Metritis facing  104 

14.  Uterus  and  Adnexa  from  a  Case  of  Pelvic  Inflammatory  Disease facing  106 

1.5.  Uterus  and  Appendages  from  a  Case  of  Advanced  Pelvic  Inflammatory  Disease, 

with  Bilateral  Tubo-ovarian  Abscess facing  10^ 

10.  Acute  Gonorrheal  Salpingitis '.-. facing  108 

17.  f  lonorrheal  Salpingitis ! facing  109 

18.  Unusually  Large  Pyosalpinx facing  110 

19.  Section  Through  an  Advanced  Chronic  Pyosalpinx facing  111 

20.  Section  Through  a  Pyosalpinx , facing  112 

21.  Hydrcsalpinx facing  113 

22.  Cross-section  Through  an  Ovarian  Abscess  of  Lutein  Origin facing  114 

23.  Pyosalpinx  and  Ovarian  .\bscess facing  115 

24.  Tubo-ovarian  Cy.st facing  115 

25.  Uterus  and  Appendages  from  a  Case  of  Advanced  Pelvic  Inflammatory  Disease 

facing  116 
20.  Tubo-ovarian  .Vhsce-ss faring  1 17 

27.  .\gc  Distribution  of  Death  from  \'enereal  Disease,  Per  Cent.  (Brown,  H.  .\.:  New 

York  Med.  Jour.,  June  17,  1911,  p.  llS.'j) 126 

28.  Condylomata  Acuminata  of  the  External  Genitalia facing  198 

29.  Diagram  of  the  Blood-supply  of  the  Fallopian  Tube.  .  .' 291 

30.  Photograph  Showing  the  Arterial  Blood-supply  of  the  Normal  Tube,  Ovary,  and 

Uterus facing  292 

31.  Bilateral  Salpingectomy,  Ovarian  Conservation,  and  Suspension  of  the  Ovary  and 

Uterus.     First  Step facing  293 

32.  Richar<lson'a  Single  ia)  and  Double  (6)  Figure-of-S  Suture  (Richardson,  E.  H.: 

Jour.  Amer.  Med.  A.s.soc.,  May  7,  1910 294 

33.  Bilateral  Salpingectomy,  Ovarian  Conservation,  anil  Suspension  of  the  Ovary  and 

Uterus.     Second  Step facing  294 

34.  Bilateral  Salpingectomy,  Ovarian  Conservation,  and  Suspension  of  the  Ovary  and 

Uterus.     Tliird  Step facing  294 

35.  Acute  Purulent  Salpingitis facing  340 

36.  Carcinoma  Which  Occurred  in  ihi'  Fallopian  Tube  of  a  Young  Woman facing  304 

15 


16  LIST    OF    ILLUSTRATIONS 

FIG  PAGE 

37.  Carcinoma  of  the  Fallopian  Tube  (Higli  and  Low  Power) facing  364 

38.  Keratodermie  Blennorrhagique facing  446 

39.  Gonorrheal  Keratosis facing  448 

40.  Keratodermie  Blennorrhagique .  .  facing  448 


COLORED  PLATES 

Plate     L  Gonococci  in  Pus ' Frontispiece 

Plate    IL  Urethritis  and  Bartholinitis facing  208 

Plate  IIL  Acute  Gonorrheal  Cervicitis  and  Urethritis facing  224 


GONORRHEA  IN  WOMEN 


CHAPTER  I 
HISTORIC 

The  term  gonorrhea  originated  with  Galen/  who  described  the  con- 
dition about  A.  D.  1(50.  He  believed  gonorrhea  to  be  an  involuntary 
escape  of  semen.  The  word  itself  is  derived  from  the  Greek  yovi), 
seed;  and  ptlv,  flow.  Blennorrhea  is  a  flow  of  mucus;  blennorrhagia, 
an  outpouring  of  mucus;  whereas  pyorrhea  indicates  a  purulent  dis- 
charge. It  will  be  seen  that,  therefore,  etymologically,  the  term '"  gon- 
orrhea" is  inaccurate.  The  name  has,  however,  been  so  generally 
adopted,  and  is  in  such  common  usage,  that  any  change  of  title  of  this 
disease  would  be  ill  advised  and  lead  only  to  confusion.  "Clap,"  a 
term  so  often  applied  to  gonorrhea,  especially  in  men,  is,  according  to 
Sevediaur,  derived  from  "clapiers,"  which  were  public  shops  kept  by 
prostitutes.  Lacroix,-  however,  tells  us  that  in  Paris,  during  the  Middle 
Ages,  the  prostitutes  were  domiciled  in  a  quarter  ultimately  designated 
Clapier,  and  that  it  is  from  this  locaUty  that  the  word  derives  its  origin. 
The  terms — clap  and  gonorrhea — are  used  interchangeably  by  many 
writers.  Among  the  synonyms  of  gonorrhea  known  to  the  laity  are 
such  terms  as  drop,  nipper,  a  dose,  and  other  more  vulgar  names. 
Although  there  are  no  means  at  our  command  of  positively  identifying 
gonorrhea  in  the  early  ages,  it  is  almost  certain  that  the  disease  can  be 
traced  back  to  the  earliest  records  of  the  liuman  race,  its  progress 
through  the  generations  having  left  in  its  wake  a  blind,  halt,  maimed, 
sterile,  and  sexless  multitude.  Proksch''  reports  that  an  old  Japanese 
manuscript,  written  in  b.  c.  900,  contains  an  accurate  description  of 
gonorrhea.  The  disease  was  probably  prevalent  among  the  early 
Egyptians.'' 

Herodotus  (b.  c.  484)  relates  how,  after  the  Scythians,  during  an 
expedition  to  .\scalon,  a  city  of  Hyria,  had  despoiled  the  temple  of 

'  Galen:  Dc;  Loi:.  AITuc,  2,  S,  Edil.  Uulin,  3,  p.  i)l. 

*  Prostitution  au  Moyen  Ago,  Fol.  ii;  cf.  Du  Cangc,  Glossar.,  sub.  v,  Clapier. 

'  Prok.sch,  J.  K. :   Die  Gcschichte  d.  ven.  Krankh.,  Bonn,  P.  Hanstoin,  1895,  vol.  i,  p.  97. 

'Vi'it;  Ilandb.  il.  Gyiiiikologie,  vol.  ii. 

2  17 


18  GONORRHEA    IN   WOMEN 

Venus  Urana,  they  were  attacked  by  a  disease  called  "thenousos 
thelia."  This  was  in  all  probability  gonorrhea.  Hippocrates  men- 
tions dijsuria,  and  speaks  of  a  whitish  leukorrhea.  Ureteral  and  pre- 
putial ulcers  are  described  by  Celsus  (a.d.  164),  who  also  refers  to  a 
purulent  or  bloody  discharge  issuing  from  the  canal  and  orchitis,  but 
does  not  mention  that  this  was  due  to  or  followed  sexual  congress. 
His  treatment  consisted  of  cold  baths,  massage,  with  the  local  applica- 
tion of  rue  and  vinegar,  and  food  and  drinks  of  a  cooling  nature. 
Galen  (a.  d.  130)  believed  that  gonorrhea  was  due  to  the  semen  hav- 
ing acquired  a  poisonous  quaUty.  A  similar  view  was  held  by  Pliny 
(a.  d.  115).  Marcellus  Empiricus,  physician  to  the  Emperor 
Theodosius,  gives  his  treatment  for  what  was  probably  gonorrhea. 
AU  Abbas  writes  of  the  symptoms  of  urethritis,  and  recommends 
various  refrigerant  and  sedative  remedies,  such  as  coriander,  lentils, 
fleawort,  poppies,  roses,  henbane,  and  lettuce,  together  with  emetics 
and  blood-letting,  if  the  patient  be  of  a  plethoric  habit.  He  also  ad- 
vises sleeping  in  a  cool  bed  and  the  wearing  of  a  metal  plate  over  the 
loins.  Dioscorides'  recommends  the  internal  use  of  hemlock.  Maim- 
onides  describes  urethritis  as  follows :  ' '  The  fluid  escapes  without  erec- 
tion and  without  a  feeling  of  pleasiii-e;  the  appearance  of  the  discharge 
is  similar  to  that  of  barley  dough  dissolved  in  water  or  coagulated  al- 
bumin, and  is  the  result  of  an  internal  disease;  it  is  essentially  differ- 
ent from  the  seminal  fluid  and  mucus,  the  latter  being  more  homogene- 
ous." The  same  writer  mentions  a  number  of  causes  for  the  disease, 
including  amorousness  and  excesses  of  various  kinds.  Other  references 
to  venereal  diseases,  probably  gonococcal  in  origin,  may  be  found  in 
the  works  of  Juvenal,  Martial,  Sextus  Placidus,  Scribonius,  and  Are- 
t£eus.  Although  we  have  no  indisputable  record  that  gonorrhea  ex- 
isted among  the  Romans,  it  seems  practically  certain  that  this  was  the 
case.  Rome  was  the  richest  city  in  the  world — a  city  whose  inhabi- 
tants numbered  four  milUons  (Lipsius) ;  an  era  of  peace,  luxury,  and 
vice  hitherto  unknown  in  the  world's  history  had  settled  over  the 
community.  Prostitution  was  rife.  Even  Agrippina  would  leave 
the  palace  of  the  Caesars  to  spend  the  night  in  the  brothels  of  the  city. 
CaUgula  had  a  brothel  in  his  palace.^  Nero  was  a  habitual  frequenter 
of  houses  of  prostitution,  and  dined  in  public  at  the  great  circus  with 
hordes  of  prostitutes.  The  pubhc  baths,  which  were  used  by  men  and 
women,  boys  and  girls,  all  in  a  state  of  complete  nudity,  were  little 
more  than  houses  of  assignation.^  According  to  Herodotus,  the  women 
threw  aside  their  modesty  with  their  clothes.     The  aliptes,  or  sham- 

'  Dioscorides:   Meth.  med.,  vol.  iv,  p.  79. 

-Juvenal:  Sat.,  vi.  Pliny:  Nat.  hist.,  33,  54. 


HISTORIC  19 

pooers,  who  massaged  the  bathers,  were  members  of  the  lowest  class. 
The  most  virtuous  private  citizens  decorated  the  walls  of  their  houses 
with  lewd  sculptures  and  lascivious  frescoes.'  The  character  of  the 
Roman  banquets  is  too  well  known  to  need  description.^  Statues  of 
Venus  and  of  the  god  Priapus  were  exhibited  freely  to  the  public  gaze. 
Offerings  were  made  to  these  deities  in  the  form  of  small  cakes  repre- 
senting the  female  and  male  organs  of  generation,  and  were  sold  in  all 
the  bakeries.  The  monstrous  indecency  of  the  statues  of  Priapus  was 
their  chief  feature — an  image  that 

"  Maids  peer  at  through  fingers  hekl  before  the  face."  ^ 

The  law  regarded  all  servants  waiting  upon  travelers  at  inns  or 
taverns  as  prostitutes.  Among  all  classes  immorality  reigned  supreme. 
Well  might  Juvenal  cry,  "Vice  has  culminated!"^  Amid  such  de- 
praved conditions  venereal  disease  must  surely  have  thrived  apace. 
In  spite  of  this,  these  diseases  occupy  but  a  small  space  in  the  medical 
hterature  of  this  period.  This  is  due  to  two  facts:  first,  the  Roman 
physicians  did  not  generally  allude  to  these  diseases,  believing  that 
they  were  beneath  their  dignitj'.  Thus  Celsus,  before  referring  to  the 
subject,  apologizes  for  mentioning*  the  disease — "Quse  invitissimus 
quigue  alteri  ostendit";^  and,  secondly,  the  Roman  phj'sicians  re- 
fused to  treat  venereal  diseases,  which  we  find  referred  to  under  the 
general  term  "morbus  indecens."  As  a  consequence,  the  rich  were 
treated  by  their  slave  doctors,  whereas  the  poor  were  probably  at- 
tended by  the  archiatri.  who  occupied  somewhat  the  same  position 
as  docs  the  district  physician  of  the  present  day,  and  who  were  bound 
to  treat  all  diseases  among  the  poor  gratuitously,  although  they  might 
demand  a  fee  from  the  wealthy." 

For  diseases  of  the  groin  the  Romans  used  a  plant  called  "bu- 
boniuin,"  from  which  the  term  "bubo"  d()ul)tless  took  its  origin. 
To  the  (ireeks  this  remedy  was  known  as  honboniinn.  Roman  women 
affected  with  secret  disea.ses  were  called  aucunnuenUr,  a  term  that 
explains  itself.  The  Romans  said  of  a  female  who  communicated  a 
disease  to  a  man,  "Haec  to  imbubinat"  (Scalinger).  Sanger"  states 
that  no  pas.sage  in  the  ancient  writers  directly  ascribes  venereal  dis- 
eases to  commerce  with  prostitutes,  but  adds,  however,  that  no  medical 

'  Propcrtiu.s:  ii,  0;  Suet.:  Tib.  luul  Vil.  Ilor.;  I'liiiy:  xxxv,  ;}?;  sec  also  llir  ccillic- 
tioMS  at  I  he  Mu.seo  B()rl)oni(.'c  at  Naples,  etc. 

'  IVtrori:  Satyr,  vol.  ii,  pp.  tiS,  "0.  "  Martial;  vol.  iii,  p.  (iO. 

'Juvenal:  Sat.  vi.  '  "What  all  men  unwillingly  show." — (Trans.) 

"  Dig.  27,  i,  (i;  Cod.  Theoiios.,  xiii,  .'5.     I)e  .\Ie(lic.  el  profess. 

•  S.iMii.r.  \V.  W.:  The  History  of  I'rostitutioii,  Th.'  .Me.lical  I'uhlishii.n'/ 'o.,  N'lAV  York. 
HMHl.  p.  N.-) 


20  GONORRHEA    IN   WOMEN 

reader  of  the  history  of  Rome  under  the  Empire  can  doubt  but  the 
archiatri  filled  no  sinecure,  and  that  a  large  proportion  of  the  diseases 
they  treated  were  directly  traceable  to  prostitution. 

The  morality  of  the  Greeks  was  no  better  than  that  of  the  Romans, 
and  it  is  probable  that  venereal  diseases  were  by  no  means  unknown. 
Indeed,  Dufour^  states  that  it  was  the  fear  of  venereal  diseases  that 
was  responsible  for  many  of  the  sexual  perversions  of  the  ancient 
Greeks. 

That  the  ancient  Jews  were  acquainted  with  gonorrhea  and  were 
aware  of  its  contagiousness  there  can  be  little  doubt.  In  the  fifteenth 
chapter  of  Leviticus,  Moses,  about  B.C.  1471,  not  only  warned  the 
children  of  Israel  of  the  dangers  of  gonorrhea,  but  laid  down  definite 
sanitary  and  pohce  regulations  for  its  prophylaxis,  many  of  which  might 
be  adopted  with  advantage  at  the  present  day.  In  Deuteronomy, 
chapter  xxiv,  verse  1,  it  is  stated  that  if  a  man  marry  a  woman 
"and  it  come  to  pass  that  she  find  no  favour  in  his  eyes,  because  he 
hath  found  some  uncleanness  in  her;  then  let  him  write  her  a  bill  of 
divorcement."  The  historian  Josephus  relates  how  the  Jews,  on 
their  way  to  Canaan,  contracted  venereal  diseases.  In  the  Jerusalem 
Talmud  numerous  references  are  made  to  gonorrhea,  and  in  the  Baby- 
lonian Talmud  venereal  diseases  are  frequently  mentioned.  After  a 
careful  study  of  both  Talmuds  there  can  be  little  doubt  in  the  reader's 
mind  that  gonorrhea  played  an  important  role  in  the  etiology  of  the 
diseases  of  women  in  ancient  times.  In  Numbers  v  :  ii  we  find  the 
Israelites  instructed  to  "put  out  of  the  camp  every  leper,  and  every 
one  that  hath  an  issue."  It  should  be  stated  that  some  difference  of 
opinion  has  existed  in  regard  to  the  interpretation  of  the  word  "issue." 
Some  authorities  believe  that  this  does  not  refer  to  a  venereal  disease, 
and  base  their  argument  on  the  thirteenth  verse  of  the  fifteenth  chap- 
ter of  Leviticus,  which  says :  ' '  \^^ien  he  that  hath  an  issue  is  cleansed 
of  his  issue ;  then  he  shall  number  to  himself  seven  days  for  his  cleans- 
ing." It  is  urged  that  if  the  word  "issue"  referred  to  a  venereal  dis- 
ease, the  patient  could  hardly  expect  to  be  cured  in  eight  days.  This 
interpretation,  however,  appears  incorrect,  for  if  we  consider  the 
twenty-eighth  verse  of  the  same  book  and  chapter,  which  deals  with 
menstruation,  we  find,  "But  if  she  be  cleansed  of  her  issue,  then  she 
shall  number  to  herself  seven  days  and  after  that  she  shall  be  clean." 
From  this  it  would  appear  that  the  proper  interpretation  of  verse  13 
should  be  that  "when  he  hath  an  issue  and  is  cleansed  of  his  issue 
(after  being  quite  cured),  he  shall  then  number  to  himself  seven  daj^s 
for  his  cleansing." 

'  Dufour:   History  of  Prostitution. 


HISTORIC  21 

In  the  writings  of  the  IMiddle  Ages  many  references  to  gonorrhea 
occur.  Among  works  of  the  early  Arabian  writers  there  are  numerous 
and  accurate  descriptions  of  the  symptoms  and  methods  of  treatment. 
Accurate  dates  of  the  various  writings  of  this  period  are  obtained  with 
difficulty,  but  Johannes  Mesue  writes  in  the  tenth  or  eleventh  century 
as  follows:  "Si  vero  in  via  et  ductus  uriuEe  ulcera  sunt,  cognoscuntur 
ex  dolorc  majis  in  urinse  egrissione  et  sanie  egrediente  ante  urinam. 
Ulcera  virga?  et  apostemata  sunt  proportionalia  ulceribus  et  apostema- 
libus  testium."^  Ebu  Sina  describes  urethritis  thus:  "Sentitur  acuitus 
et  mordicatio  in  egressione  et  quandoque  est  cum  eo  ardor  urinse,  et 
est  color  ejus  ad  citrinitatem  declinis.'"-  Serapion  gives  a  clear  de- 
scription of  the  suppurations  of  the  external  genitaha  of  women,  which 
he  believed  were  due  to  sexual  excesses.  He  also  writes  at  length  of 
urethritis  in  the  male,  and  recommends  the  use  of  hemp  in  its  treat- 
ment. Rhanges  describes  a  disease  that  caused  burning  during  mic- 
turition. In  the  eleventh  century  Albucasis'  treated  urethritis  by 
injections  of  vinegar  and  water.  It  is  interesting  to  note  that  most  of 
the  earlier  writers  gave  but  little  attention  to  gonorrhea  in  the  female, 
the  intraperitoneal  complications  of  which  were  not  recognized. 
Michael  Scotus,^  physician  to  Emperor  Frederick  I,  in  the  early  part 
of  the  thirteenth  century,  recognized  the  infectious  character  of  gon- 
orrhea. CJariopontus  also  discusses  the  disease.  Lenfrancus,  a  dis- 
tinguished physician  of  the  thirteenth  century,  who  received  his  early 
surgical  training  in  Paris  in  1295-1306,  and  who  was  a  pupil  of  William 
de  Saliceto,  describes  the  induration  of  the  testicles.  He  also  recog- 
nized the  infectious  nature  of  gonorrhea,  and  as  a  prophylactic  recom- 
mended washing  the  penis  in  vinegar  and  water  after  coitus.  Guido 
de  Cauliaco,  in  his  "Surgery,"  mentions  urethritis  as  a  condition  fol- 
lowing intercourse  with  a  diseased  woman.  Constantinus  Africanus 
recommends  remedies  for  strangury.  Johannes  de  Gaddesden  wrote  of 
vaginitis,  urethritis,  and  epididymitis.  Johannes  Ardern,  physician  to 
Richard  II  and  Henry  IV,  believed  urethritis  to  be  due  to  excoriation 
of  the  urethra,  and  recommends  as  treatment  injections  of  human  milk, 
to  which  were  added  almond  milk,  sugar,  and  violet  oil.  Antonio 
Cermisone,  a  professor  in  Pavia  and  in  Padua,  and  who  died  in  the 
latter  place  in  1441,  recognized  gonorrhea  as  an  infectious  disease  and 

'  "The  prcst'iicp  of  ulfors  on  tho  urethra  may  be  rpcognizod  by  the  occurrence  of  seveie 
pain  on  urination  ami  tlic  ilischarKc  of  purulent  secretion  and  .shreds  of  tissue.  The  ulcers 
correspond  with  those  on  the  penis  and  on  tlie  testes." — (Trans.) 

'  "Sharp  pain  and  itching  are  experienced  during  urination,  and  burning  and  smarting 
are  present  along  the  entire  urethral  canal.  The  urine  is  of  a  light  lemon-yellow  color." — 
(Tians.) 

'  .\lbucasis:  Lil).  theoret.  nee.  non  pract.  .\l.sahar.  .\ngus  Windel.  l.")l(l,  fol..  p.  !)2a. 

'  Scotus:   De  Procr.  et  horn.  Physion.,  op.  S.  1,  1477,  ('ap.  O-IO. 


22  GONORRHEA    IN    WOMEN 

treated  it  by  means  of  astringents.  Further  references  to  gonorrhea 
may  be  found  in  the  works  of  Joannes  Arculanus,  Valescus  de  Taranta, 
Magninus,  Guhehnus  Vareguana,  Antonio  Cermisone,  Johannes  de 
Tornamira,  and  many  others.  Beckett  tells  us  of  an  ordinance  formu- 
lated by  the  Bishop  of  Winchester  for  the  purpose  of  checking  the 
spread  of  gonorrhea.  One  of  the  articles,  "De  his  qui  custodiant  mu- 
lieres  habentes  nefandam  infirmatatem,"  reads  as  follows:  "That  no 
Stewholder  keep  noo  woman  wythin  liis  hous,  that  hath  any  sycknesse 
of  Brenning"  (the  perilous  infirmity  of  burning).  This  ordinance  is 
said  to  date  back  to  the  year  1162.  Another  ordinance  of  this  Bishop 
is  to  the  effect  that  no  woman  affected  with  ' '  the  perilous  infirmity  of 
burning"  shall  be  harbored  in  any  of  the  eighteen  houses  of  prostitu- 
tion that  were  situated  in  Southwark,  and  were  said  to  have  been  under 
his  jurisdiction.  A  somewhat  similar  ordinance  was  found,  dated 
August  8,  1343,  and  attributed  to  Joanna  I,  Queen  of  both  Sicilies,  the 
fourth  article  of  which  was  as  follows:  "The  Queen  commands  that 
the  Superintendent  and  a  surgeon,  appointed  by  the  authorities,  ex- 
amine, every  Saturday,  all  the  whores  in  the  houses  of  prostitution. 
And  if  one  is  found  who  has  contracted  a  disease  from  coitus,  she  shall 
be  separated  from  the  rest  and  live  apart,  in  order  that  she  may  not 
distribute  her  favors  and  may  thus  be  prevented  from  conveying  dis- 
ease to  the  young  men."  The  fear  of  venereal  diseases  in  the  early 
ages  was  very  'great.  Sanger^  informs  us  that  afflicted  individuals 
were  driven  into  the  fields  to  die,  the  physicians  refusing  to  attend  the 
sick  for  fear  of  becoming  infected.  He  also  adds  that  many  writers 
doubted  this  form  of  contagious  influence,  and  held  that  it  required 
intercourse,  or  at  least  contact.  But  nobles,  and  especially  the  clergy, 
preferred  to  ascribe  their  maladies  to  misfortune  rather  than  to  licen- 
tiousness, and  sought  to  "put  down"  such  innovations.  The  conse- 
quence of  this  view  was  that  any  but  wealthy  venereal  patients  had 
extreme  difficulty  in  obtaining  treatment,  and  as  a  result  many  severe 
cases  were  found.  This  lack  of  treatment  doubtless  partiallj^  accounts 
for  the  supposed  malignancy  of  venereal  diseases  of  this  period. 

Toward  the  end  of  the  fourteenth  century  it  would  seem  that  the 
infectious  nature  of  gonorrhea  and  the  mode  of  its  contagiousness 
were  pretty  definitely  recognized.  Numerous  ordinances  and  police 
regulations  for  its  control  were  in  force,  and  medical  supervision  of 
houses  of  prostitution  was  inaugurated.  At  this  time  it  would  appear 
that  a  fairly  definite  distinction  was  made  between  syphihs  and  gon- 
orrhea. Owing  to  the  prevalence  of  venereal  disease  James  IV,  in 
1497,  issued  his  celebrated  proclamation,  banishing  all  the  infected 
>  Sanger:  The  History  of  Prostitution,  1906. 


HISTORIC  23 

from  the  city  of  Edinburgh.  This  proclamation,  however,  was  prob- 
ably aimed  at  syphilis  more  than  at  gonorrhea.  In  London,  in  1430, 
during  the  reign  of  Henry  VI,  a  police  regulation  was  in  force  excluding 
all  venereal  patients  from  public  hospitals,  and  requiring  them  to  be 
strictly  guarded  at  night.  Just  how  this  guarding  was  to  be  carried  out 
is  not  stated.  In  the  reign  of  Henry  VIII  there  were  six  lazar-houses  in 
London  for  the  reception  of  venereal  patients.  All  were  located  some 
distance  from  the  city  proper.  Toward  the  end  of  the  fifteenth  cen- 
tury Europe  was  swept  by  an  epidemic  of  syphihs.  So  se^'ere  and 
devastating  was  this,  and  of  so  mahgnant  a  character  was  the  disease, 
that  gonorrhea  sank  into  comparative  insignificance.  Up  to  this  time 
a  definite  distinction  had  been  made  by  most  authors  between  the  two 
diseases. 

The  sixteenth  century,  as  regards  venereal  diseases,  is  generally 
looked  upon  as  one  of  confusion.  At  this  time  syphilis,  which  was  so  wide- 
spread, was  a  comparatively  new  disease,  and  was  but  little  understood 
by  many  physicians.  It  has  previously  been  pointed  out  that  the  early 
writers  paid  but  scanty  attention  to  the  occurrence  of  gonorrhea  in 
the  female,  and  with  our  present  knowledge  of  the  latency  of  this 
disease  in  the  external  genitalia  of  women,  and  the  difficulty  of  diagnosis 
even  with  our  present-day  methods,  the  attitude  of  the  earlier  physi- 
cians can  readily  be  understood.  Endometritis  and  endocervicitis 
were  regarded  as  uterine  catarrh,  and  their  etiologic  association  with 
gonorrhea  was  unknown.  The  intraperitoneal  complications  of  gon- 
orrhea were  not  recognized.  What  wonder,  then,  that  James  Cuta- 
ncus,  in  1504,  stated  positively  that  gonorrhea  could  be  contracted 
from  a  healthy  woman — an  opinion  shared  by  many  eminent 
authorities  at  a  much  later  date.  Paracelsus,'  as  early  as  1530, 
regarded  gonorrhea  as  a  complication  of  syphilis.  This  opinion 
was  shared  by  Musa  Brassavolus  (1553),  and  later  by  his  pupil, 
Gabriello  Fallopius.  In  this  view  these  physicians  were  almost 
alone. 

However,  from  the  appearance  of  the  first  epidemic  of  syphilis 
early  in  the  fifteenth  century,  a  general  change  seems  to  have  taken 
place.  Joannes  de  Vigol  (1513),  in  his  "Surgery,"  in  Chapter  de 
Auxiliis  ^Egritudinum  Virga?,  writes  in  detail  of  gonorrhea  and  its 
treatment.  Marcellus  Camanus  (1495),  a  military  surgeon  of  the 
Venetian  army  during  the  period  of  the  first  epidemic  of  syphilis,  and  a 
physician  of  extensive  experience  in  venereal  diseases,  and  .\lexander 
B(Mic(Hctus  (1510),  both  discu.ssed  syphilis  and  gonorrhea  separately. 

'  I'aracel«ii.s:   Von  d.  franzos.  Kriink.,  Xurcmhurii;,  1.529. 


24  GONORRHEA    IN    WOMEN 

In  1527  Jacques  de  Rethencourt,  of  Rouen,  wrote  an  interesting  history 
of  gonorrhea,  and  was  the  first  to  use  the  term  venereal  in  conjunction 
with  diseases  pertaining  to  sexual  intercourse.  In  England,  Simon 
Fish  (1530),  Andrew  Boord  (1546),  Michael  Wood,  and  WiUiam  BuUeyn 
(1560)  describe  gonorrhea,  particularly  in  women,  as  a  disease  distinct 
from  syphilis.  During  the  sixteenth  century  gonorrhea  seems  to 
have  been  very  prevalent  in  England,  especially  among  the  prosti- 
tutes. The  disease  was  considered  but  a  symptom  of  syphilis,  and  was 
so  treated  by  such  prominent  writers  as  Petronius^  (1565),  Martiniere- 
(1644),  Sydenham'  (1680),  Devaux  (1711),  Turner^  (1717),  and  many 
others.  As  a  result  of  this  mistaken  view,  gonorrhea  was  treated 
vigorously  with  mercury,  guaiac,  and  sarsaparilla.  In  a  -treatise 
published  in  1563  we  read:  "The  final  symptom  of  syphilis  is  Gallic 
gonorrhea — thirty  years  may  elapse  before  the  discharge  begins." 
However,  more  rational  views  regarding  the  etiology  of  syphilis  and 
gonorrhea  were  held  by  some  of  the  more  acute  diagnosticians. 
P.  Haschard  (1554)  wrote,  warning  against  the  prevalent  treatment  of 
gonorrhea  by  large  doses  of  mercury,  stating  that,  in  his  opinion,  the 
diseases  were  distinct  and  separate. 

According  to  Stephenson,^  the  recognition  of  the  connection  be- 
tween leukorrhea  in  the  mother  and  ophthalmia  in  tlie  infant  dates  to 
the  year  1750,  when  G.  S.  T.  Quellmalz"  insisted  upon  the  point.  The 
fact  was  also  mentioned  by  J.  G.  Goetz^in  1791,  by  C.  G.  Selle  in  1793, 
and  by  A.  Schmidt^  in  1806.  Gibson^  also  deserves  credit  for  noting  the 
clinical  relationship  between  leukorrhea  and  ophthalmia.  Morrison'" 
(1808)  and  Saunders'^  (1811)  also  wrote  confirming  these  views. 
But  it  remained  for  Vetch,'-  in  1820,  to  prove  by  experimental  inocu- 
lation the  truth  of  Gibson's  assertion.  Further  references  of  historic 
interest  regarding  ophthalmia  maj^  be  found  in  the  works  of  Simmons'' 

'  Petronius:   De  Morb.  Gallic,  lib.,  September,  150.5. 
2  Martiniere:  Traitd  de  la  mal.  veneriennes,  1664. 
"     '  Sydenham:  Epist.  d.  luis  vener.  Hist,  et  curat.,  London,  16S0. 
■"Turner:  Syphilis,  etc.,  London,  1717. 

'  Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  22. 
^    "  Quellmalz,  G.  S.  T.:  Cent.  f.  prak.  Augenheilkunde,  February,  1S94. 
'  Goetz,  J.  G. :  De  Ophthalmia  Infantum  recens  natorum. 

»  Schmidt,  A.:  Ophthalmologische  Bibliothek  (K.  Himly  u.  J.  A.  Schmidt),  1806,  vol. 
iii.  No.  2,  p.  107. 

'  Gibson,  B.:  Edinburgh  Med.  and  Surg.  Jour.,  1807,  p.  160. 

-  10  Morrison:  Med.  and  Physical  Jour.,  1808,  vol.  x.\,  p.  57. 

"  Saunders,  J.  C:  A  Treatise  on  Some  Practical  Points  Relating  to  the  Disease  of  the 
Eyes,  London,  1811. 

-  '2  Vetch:  Practical  Treatise  on  the  Diseases  of  the  Eye,  1820,  p.  242. 

"  Simmons,  W.:  Edinburgh  Med.  and  Surg.  Jour.,  1809,  vol.  v,  p.  283. 


HISTORIC  25 

(1809),  Ware'  (1814),  Hagewisch.^RyalP  (1824),  Green^  (1824),  Wat- 
son^ (1828),  Wisharf^  (1829),  Jacob^  (1834),  CarmichaeP  (1839), 
Edwards'  (1840j,  Lawrence'"  (1844),  Whitehead"  (1847),  Watson'- 
(1848),  Oke"  (1852),  Tyler-Smith'^  (1853),  Crede'=  (1853),  Mackenzie'^ 
(1854),  Guyomor''  (1858),  Walton'^  (1865),  Wells"*  (1865),  Wilson^" 
(1866),  Xoeggerath-'  (1872),  Hulke"  (1873),  Ballard^'  (1859),  Hogg" 
(1875j,  Neisser"  (1879),  and  others  that  have  been  collected  by  Steph- 
enson-^ in  his  excellent  monograph. 

Until  1753  the  prevailing  opinion  was  that  a  urethritis  was  due  to 
the  presence  of  an  ulcer  within  the  urethra.  At  about  the  beginning 
of  the  eighteenth  century  the  opposition  to  the  incorrect  views  held 
regarding  the  etiology  of  gonorrhea  and  syphilis  began  to  become  more 
insistent.  Nevertheless,  it  was  not  until  the  end  of  the  eighteenth 
centurj'  that  the  separate  identity  of  these  two  diseases  was  generally 
accepted.  At  this  time  Finger  and  others  write  of  the  existence  of 
two  schools  of  syphilologists — the  identists,  who  believed  in  the  iden- 
tity of  the  virus  of  gonorrhea  and  of  syphilis,  and  the  dualists,  who  held 
the  contrar}' view.     Hales"  (1770)  advocated  the  complete  separation 

'  Ware,  J.:   Kemjirk.s  on  OphthalmjvlSU,  p.  126. 

-  Hagewisch:  Horn's  Arch.  f.  prak.  Med.,  vol.  iii,  p.  208. 

'  Ryall,  J.:  Trans,  .\ssoc.  of  the  Fellows  and  Licentiates  of  the  King  and  Queens 
College  of  Physicians  in  Ireland,  1824,  vol.  iv,  p.  340. 

*  flrcen:  Lancet,  February  1.5,  1824,  p.  213. 

'  Watson,  A.:  X  Compendium  of  the  Diseases  of  the  Human  Eye, second  edition,  p.  34. 

"  Wishart,  J.  H.:  ICdinburgh  Med.  and  Surg.  .Tour.,  1829,  vol.  xxxii,  p.  253. 

'Jacob,  A.:  ■'Ophthalmia,"  in  Cj'clopa'dia  of  Practical  Mod.  by  Forbes,  Tweedie 
and  Conoll}',  vol.  iii,  p.  198. 

'  Carmichael,  H.:  Dublin  Jour.  Med.  Sci.,  1839,  vol.  xv,  p.  200. 

»  Edwards,  C:  Lancet,  July  4,  1840. 

"  Lawrence,  W.:   \  Treatise  on  the  Diseases  of  the  Eye,  1844,  p.  22. 
"Whitehead,  J.:  Provincial  Med.  and  Surg.  Jour.,  1847,  p.  .')3G. 
"  Watson,  T.:   Lectures  on  the  Principles  and  Practice  of  Physic,  1848,  vol.  i,  p.  309. 
"  Oke,  W.  S.:  Provincial  Med.  and  Surg.  Jour.,  18.52,  p.  29. 
"  Tyler-Smith,  W.:  Lancet,  August  20,  1853,  p.  157. 
'*  Crcd(5:   KHnische  Vortrage  iibcr  Geburts.,  1853,  vol.  i,  p.  IGO. 

"  Mackenzie,  W.:  Practical  Treatise  on  the  Diseases  of  the  Eye,  fourth  edition,  1854. 
"  Ouyomor,  D. :  Tli6se  de  Paris,  1S58,  p.  45. 
"  Walton,  IL:   .Med.  Times  and  Gazette,  18G.5,  vol.  i,  p.  .5.59. 
"  Wells,  J.  S.:   Lancet,  Augu.st  21,  1865. 

»  Wilson:  Dublin  (iuarteily  Jour.  Med.  Sci.,  1866,  vol.  xhi,  p.  184. 
"  Noeggerath,  E.:    Die  latentc   (ionorrhoe    iin   weiblichen  (leschlciht ;   also   Trans. 
Amor.  Gyn.  Soc,  1876,  vol.  i.  p.  26S  et  .seq.  i 

"  Hulke:  Med.  Times  and  Gazette,  1873,  vol.  ii,  p.  629. 
-'  Hallard,  J.:   Brit.  Med.  Jour.,  1859,  p.  411. 
"  Hogg,  .1.:   Med.  Press  and  Circ,  March  31,  1875. 
■'  Neisser,  A.:  Cent.  f.  med.  Wi.ssens.,  July  12,  1879. 
■' Stephen.son,  .S.:  Ophthalmia  Xeonalonun,  London,  1907. 

■'Hales:  Salivation  not  Necessary  for  the  Cure  of  Venereal  Diseases,  etc.,  London, 
1764;  also  letter  addres.sed  to  Caesar  Hawkins,  etc.,  London,  1770. 


26  GONORRHEA    IN    WOMEN 

of  gonorrhea  and  the  chancre  virus.  EUis,  in  1771,  conducted  a  series 
of  experiments  that  strengthened  the  beUef  that  these  were  two  dis- 
tinct diseases.  Bayford,  in  1773,  wrote  opposing  Ellis's  views,  basing 
his  conclusions  on  the  fact  that  he  was  unable  to  detect  with  the 
microscope  any  difference  between  gonorrheal  and  syphiUtic  pus. 
Tode  (1774)  combated  the  identity  of  gonorrhea  and  syphilis.  Dun- 
can (1777)  advanced  the  argument  that  the  inhabitants  of  Otaheite 
were  familiar  with  syphilis  long  before  gonorrhea  was  introduced 
among  them.  Mr.  Wilson,  surgeon  to  H.M.S.  Porpoise,  visited 
Otaheite  in  1801,  and  after  a  careful  investigation  came  to  the  con- 
clusion that  gonorrhea  was  then  unknown  on  that  island.  Harrison 
(1781)  and  Swediaur  (1784)  employed  the  experimental  method,  but 
their  results  led  them  to  suppoi-t  the  view  that  syphilis  and  gonorrhea 
were  identical. 

Sir  John  Hunter^  became  deeply  interested  in  this  controversy, 
and  on  a  Friday  morning  in  May,  1767,  performed  the  famous  experi- 
ment that  was  destined  to  retard  the  medical  progress  of  his  day  for 
many  years.  Hunter  offered  himself  as  a  sacrifice  for  the  cause  under 
dispute.  He  made  two  punctures  in  his  penis  with  a  lancet  dipped  in 
venereal  matter  taken  from  a  supposed  case  of  gonorrhea — one  punc- 
ture was  made  in  the  glans  and  the  other  in  the  prepuce.  As  a  result, 
he  developed  syphilis.  The  inguinal  glands  became  enlarged,  a 
mucous  patch  appeared  on  one  tonsil,  and  a  copper-colored  rash  de- 
veloped. As  a  consequence  of  this  experiment  Hunter  came  to  the 
conclusion  that  syphilis  developed  from  gonorrhea.  The  suggestion 
is  made  by  Palmer-  that  Hunter,  during  one  of  the  repeated  dressings 
of  the  wounds  on  the  penis,  may  have  inoculated  the  sores  with  syphi- 
litic virus.  The  other — and  the  more  likely — explanation  seems  to  be 
that  a  urethral  chancre  was  in  the  first  place  mistaken  for  a  gonorrhea. 
In  view  of  Hunter's  upright  character  and  well-known  veracity  no 
other  explanation  is  tenable.  There  can  be  no  doubt  that  Hunter, 
although  a  keen  observer,  was  impulsive,  and  likely  to  form  hasty 
conclusions.  Hunter'  was  considered  at  this  period  the  first  surgeon, 
the  first  physician,  and  perhaps  the  first  scientist  in  all  Europe.  So 
well  known  was  he,  and  so  large  a  following  had  he,  that  this  "personal 
experiment"  could  not  fail  to  carry  great  weight,  even  with  those  who 
believed  in  the  separate  identity  of  gonorrhea  and  syphilis.  It  is  true 
that  Hunter  distinguished  between  a  "venereal"  and  a  "simple" 
gonorrhea,  and  believed  that  the  latter  could  develop  from  causes 
other  than  coitus,  or  even  spontaneously,  but  he  did  not  describe  his 

'  Hunter:  Works,  edited  by  John  Palmer,  New  York,  1841,  vol.  ii. 

=  Hunter:   Loc.  f?7.  Ulunter:    Loc.  cit. 


HISTORIC  27 

differential  diagnosis  clearlj'.  He  considered  gleet  non-infectious.  It 
seems  a  cruel  irony  of  fate  that  Hunter,  after  sacrificing  himself  for 
the  cause  of  science,  should  have  been  forced  into  the  position  of  the 
leader  of  a  movement  that  has  since  been  proved  to  have  been  a  retro- 
gression involving  some  sixty  years. 

Even  so  late  as  1829  mercury  was  used  in  the  treatment  of  gon- 
orrhea in  some  of  the  large  London  hospitals,  notwithstanding  the  fact 
that  the  Edinburgh  school,  through  such  men  as  Hales  (1770),  How- 
ard' (1787),  and  Bell-  (1793),  taught  that  gonorrhea  and  syphihs  were 
different  diseases.  Hogan's  (1787)  opposition  to  Hunter's  doctrines 
went  unnoticed.  In  1793  Benjamin  BelP  conducted  a  series  of  experi- 
ments that  attracted  considerable  attention.  Among  other  evidence 
that  he  adduced  pointing  to  the  separate  identity  of  gonorrhea  and 
syphiUs  was  an  experiment  made  upon  two  physicians,  in  whom  gon- 
orrheal pus  was  inoculated  into  the  urethra,  and  neither  of  whom  de- 
veloped syphihs.  Clossius  (1797)  coincided  with  Bell's  conclusion. 
Evans  and  Le  Bon  (1789),  by  their  experiments,  strengthened  Bell's 
position.  Herandez  (1811)  inoculated  seventeen  convicts  with  gon- 
orrheal pus  and  all  developed  gonorrhea.  Not  one  contracted  syphilis 
as  a  result  of  the  test.  This  was  undoubtedly  a  most  important  ex- 
periment, and  carried  great  weight  with  the  mecheal  profession  in 
general.  A  new  dispute  now  arose.  C'aron  (1811),  Desruelles  (1826), 
and  Devergie  (183(5)  taught  that  gonorrhea  was  devoid  of  any  specific 
virus,  and  that  it  was  not  a  contagious  disease.  The  careful  and  exact 
Germans  had  by  this  time  come  to  the  conclusion  that  gonorrhea  was 
an  entirely  different  disease  from  syphilis.  They,  however,  denied  its 
local  character  and  regarded  it  as  a  general  infection.  In  the  works 
of  Autheuriet  (1809),  Ritter  (1819),  and  Eisenmann  (1830)  we  find 
descriptions  of  various  sequela;  or  metastases  of  urethritis,  such  as 
gonorrhea  of  the  lung,  ear,  and  meninges,  gonorrheal  ulcer,  neuroses, 
amaurosis,  and  congenital  and  acfiuired  gonorrheal  diatheses.  Thus 
matters  remained  in  this  unsettled  state  until  Phillippe  Hicord'  (1831- 
1837),  with  his  large  ('Xi)erience,  Ijrilliant  critical  and  dialectic  powers, 
impressed  his  teachings  forcibly  on  the  medical  profession.  This  in- 
ve.stigator  made  (j()7  inoculations  of  gonorrheal  pus  and  in  not  a  single 
case  did  syi)hilis  result.     In  later  experiments  the  .same  writer  showed 

'  Ilowiird:  I'nii-liiiil  Obscrviilions  on  the  N:iliiial  History  ami  Ciiir  of  the  NCricir.il 
OisciiMcs,  Lonildii,  17s7.  . 

'  Hell:  A  Trciitisc  on  (ionorrlica,  KdinliurKh,  i''Xi;  ilntl.:  Trcati.sr  on  (!iii.  \  iiul.  anil 
I  ncM.  London,  17M. 

'Hrll:   Lnr.ril. 

'  KiconI:  Lectures  on  \'enereal  anil(>llier  1  Jiseases  Arisiiiu  from  Sexual  InlcMcourse, 
l'liila<lil|>liia,  ISttl. 


28  GONORRHEA    IN   WOMEN 

t 

that  a  urethral  sore  could  furnish  pus  from  which  syphiUs  might  de- 
velop. These  experiments  practically  estabhshed  the  non-identity  of 
gonorrhea  and  syphilis.  No  one  can  fail,  on  reading  Ricord's  works, 
to  be  impressed  with  his  ability  and  with  the  bull-dog  tenacity  of 
purpose  with  which  he  brings  his  conclusions  to  the  foreground. 

Attention  has  previously  been  drawn  to  the  fact  that  the  early 
writers  paid  but  little  regard  to  gonorrhea  in  the  female,  and  it  was  not 
until  Noeggerath's^  epoch-making  observations  were  published  in 
1872  that  the  full  significance  of  gonorrhea  in  women  was  realized.  It 
is  true  that  in  1857  Bernutz  and  GoupiP  reported  their  observations 
of  gonorrheal  infections  of  the  appendages  and  pelvic  peritoneum,  and 
that  in  1858  West  published  a  paper  in  which  he  ventured  an  opinion 
that  in  some  cases  gonorrhea  might  extend  to  the  intraperitoneal  gen- 
erative organs.  This  view  was  subsequently  supported  by  Dobson, 
Nelson,  and  Giles,  but  received  little  support  from  the  profession  in 
general.  This  was  doubtless  due  to  the  fact  that  in  the  male  a  gon- 
orrheal urethritis  is  an  active  and  usually  painful  condition,  and  that 
a  very  large  proportion  of  urethral  discharges  occurring  in  men  are  of 
gonorrheal  origin,  whereas  in  women  urethritis  or  cervicitis  was  of 
itself  of  httle  moment,  and  rarely  produced  severe  subjective  symp- 
toms, and  that  leukorrhea  may  be  the  result  of  a  variety  of  causes. 

As  has  been  pointed  out  in  previous  pages,  Ricord's  numerous  ex- 
periments and  acute  reasoning,  together  with  the  brilliant  and  perti- 
nacious manner  in  which  his  conclusions  were  presented  before  the 
medical  world,  definitely  established  the  separate  identity  of  gonorrhea 
and  syphihs,  notwithstanding  the  fact  that  a  few  stubborn  identists, 
such  as  Eisenmann,  Vidal  de  Cassis,  Simon,  and  Caron,  were  still 
occasionally  heard  from. 

For  many  years  prior  to  the  victory  of  the  unitists,  headed  by  Ri- 
cord,  two  forms  of  urethritis  had  been  recognized  by  Hunter,'  Brassa- 
volus,  and  others.  These  two  varieties  were  spoken  of  as  gonorrhoea 
virulenta  and  gonorrhoea  simplex.  Now  that  the  gonorrhoea  viru- 
lenta,  or  syphilis,  was  satisfactorily  accounted  for,  the  question  arose, 
was  the  gonorrhoea  simplex,  or,  to  avoid  confusion,  was  gonorrhea, 
caused  by  a  specific  virus,  or  was  it  merely  the  result  of  a  simple  irri- 
tation? Ricord  taught  that  gonorrhea  was  not  a  specific  disease,  but 
was  a  simple  catarrh  that  might  be  due  to  the  action  of  various  irri- 
tants on  the  mucous  membranes.  Indeed,  one  physician  of  this 
period  has  stated  that,  in  his  opinion,  gonorrhea  might  follow  the 
exposure  incident  to  urination  in  the  night  air.     It  is  significant,  and 

'  Noeggerath,  Emil:  Die  latente  Gonorrhoe  in  weiblichen  Geschlecht,  Bonn,  1872. 
-  Bernutz  and  Goupil:  Arch.  g(?n.  de  Med.,  March,  1857.  '  Hunter:  Loc.  cit. 


HISTORIC  29 

shows  the  result  of  Ricord's  keen  powers  of  cUiiical  observation,  that 
he  regarded  the  chscharges  from  uterine  catarrh,  the  lochia,  and  the 
menstrual  flow  as  peculiarh'  likely  to  set  up  a  urethritis,  conditions  that 
we  now  know  favor  contagion  in  cases  of  chronic  gonorrhea  in  women. 
Under  predisposing  causes  of  gonorrhea  he  mentioned  age,  sex,  tem- 
perament, climate,  and  the  season  of  the  year.  Certain  food-stuffs, 
such  as  alcohol,  asparagus,  salty  foods,  and  rich  dishes  in  general,  were 
likely  to  set  up  a  urethritis.  Among  the  chief  irritants  Ricord  placed 
gonorrheal  pus  first.  This  he  believed  would  produce  gonorrhea,  not 
by  its  contagiousness,  but  merely  by  the  irritation  it  caused.  He 
maintained  that  a  similar  effect  could  be  produced  by  instrumentation 
of  the  urethra,  bj^  the  injection  of  irritating  fluids,  sexual  excesses  in 
healthy  individuals,  or  even  prolonged  sexual  excitement  without 
gratification.  To  bear  out  these  conclusions  Ricord  pointed  to  the 
fact  that  he  had  frequently  seen  urethritis  in  the  male,  and  on  examin- 
ing the  female  partner  had  found  her  entirely  healthy  and  free  from 
disease.  He  also  believed  that  a  patient  could  in  time  become  accus- 
tomed to  the  irritant,  and  might  thus  cohabit  with  the  infected  woman 
without  harmful  results,  whereas  another  would  immediatelj^  develop 
a  gonorrhea — a  fact  that  is  now  well  estabhshed.  Ricord  believed 
that  blondes  are  more  susceptible  to  gonorrhea  than  brunettes,  and  that 
women  with  leukorrhea  are  prone  to  be  infectious.  He  thought  that 
rich  foods,  alcohol,  especially  the  white  wines,  frequent  intercourse,  a 
subsequent  warm  bath,  and  urethral  injection  were  factors  that  fa- 
vored infection. 

As  late  as  1883  Mr.  Henry  Lee,  in  an  article  in  "A  System  of  Sur- 
gery" edited  by  Holmes,  makes  a  statement  confirming  Ricord's 
views,  and  concludes  as  follows:  "Gonorrhea  often  arises •frf)m  inter- 
course with  women  who  themselves  have  not  the  disease." 

To  return,  however,  to  the  time  of  Ricord:  We  find  that  there  were 
two  distinct  schools  regarding  the  genesis  of  gonorrhea — the  one  be- 
lieving with  Ricord  that  urethritis  resulted  from  a  simi)le  irritation, 
and  the  other  that  the  virus  of  gonorrhea  was  the  etiologic  factor. 
These  contrary  theories  led  to  the  performance  of  many  experiments. 
Voilleniier^  anointed  a  sound  with  pus  from  an  abscess  of  the  neck  and 
introduced  this  instrument  into  the  healthy  urethra  of  a  man,  keeping 
it  in  place  for  one  hour.  No  ill  results  followed.  This  experiment  was 
repeated  upon  another  individual,  except  that  pus  from  an  abscess  of 
the  thigh  was  used.  A  negative  result  was  obtained.  It  was  ascer- 
tained, however,  that  when  a  urethra  was  inoculated  with  pus  from  a 
vuelhritis,  gonorrhea  invariably  followed.  A  similar  result  was  ob- 
'  Voilldiiicr:  Trait ^'  dcs  ninladics  dcs  voies  urinaircs,  Paris,  1S()8. 


30  GONORRHEA    IN    WOMEN 

tained  with  pus  from  a  case  of  ophthalmia  by  Thiry,  Pauh,  Vetch/ 
de  Landau,  Otis,  and  Guyomor,^  all  of  whom  recognized  the  analogy 
between  the  two  conditions.  RosoUmes^  and  Michaelis  observed  that 
sexual  excesses  did  not  produce  gonorrhea.  Milton,''  who  for  many 
years  was  the  sole  practitioner  in  a  small  country  town,  never  saw  any 
gonorrhea  other  than  imported  cases,  and  he  assures  us,  as  Spooner 
aptly  phrases  it,  that  the  inhabitants  were  not  averse  to  "  Wein,  Weib, 
und  Gesang."  Further  arguments  were  deduced  from  the  fact  that 
virulent  gonorrhea  had  a  definite  period  of  incubation  and  ran  a  pro- 
longed course,  whereas  urethritis  the  result  of  chemical  or  traumatic 
irritants  appeared  almost  immediately  and  tended  toward  a  rapid 
spontaneous  cure. 

In  this  state  the  controversy  continued  for  over  forty  years.  Such 
eminent  authorities  as  Fournier,^  Acton,^  Robert,'  Jullien,*  Langlebert,* 
Geigel,'"  Muller,  Tarnowsky,^^  and  Bumstead'^  were  among  the  anti- 
virulists,  and  believed  that  gonorrhea  was  caused  by  a  simple  irritant, 
whereas  among  the  virulists  were  Hoelder,  Reder,"  Baume,  Milton," 
Martin  and  Belhomme,"  Lebert,  Zeissl,"  Diday,"  Sigmund,  Auspitz, 
Durkee,  and  Duyon.'* 

It  was,  however,  impossible  to  escape  the  fact  that  whenever  pus 
from  a  virulent  urethritis  was  introduced  into  a  healthy  urethra  a 
urethritis  followed,  and  that  the  resulting  infection  presented  certain 
chnical  characteristics  similar  to  the  original  case,  and  differing  quite 
radically  from  a  urethritis  caused  by  a  chemical  or  traumatic  irritation. 
It  was  also  found  that  the  amount  of  pus  used  in  the  inoculation  made 

I  Vetch:  Practical  Treatise  on  Dis.  of  the  Eye,  1820,  p.  242. 

'  Guyomor:  These  de  Paris,  1858,  p.  45. 

'  RosoUmes:  Annalcs  de  Dermatologie,  Paris,  1883,  p.  20. 

■■Milton:  Gonorrhea,  London,  1876;  also  Path,  and  Treat,  of  Gonorrhea,  London, 
1883,  2. 

'  Fournier:  Dictionary  de  Med.  et  de  Chir.  Pract.,  1866,  Art.  Blennorhce. 

*.\cton:  A  Practical  Treatise  on  Diseases  of  the  Urinary  and  Generative  Organs, 
London,  1851,  p.  30. 

'  Robert:   Maladies  Veneriennes,  Paris,  1861,  p.  64. 

'  JulUen:  Traite  Practiqvie  d.  Mai.  Veneriennes,  Paris,  1879. 

'  Langlebert:  Maladies  Veneriennes,  Paris,  1864,  p.  16. 
"•  Geigel,  A.:  Geschich.  Path.  u.  Therap.  d.  Syph.,  Wurzburg,  1867,  p.  73. 
"  Tarnowsky:  Vort.  ii.  ven.  Krank.,  Berlin,  1872,  p.  87. 
"  Bumstead:  Venereal  Diseases,  Phila.,  1879,  also  1883,  p.  56. 
"  Reder:  Path.  u.  Therap.  d.  ven.  Krank.,  Vienna,  1863. 

"Milton:  Gonorrhea,  London,  1876;  also  Path,  and  Treat,  of  Gonorrhea,  London, 
1883,  2. 

'* Martin  and  Belhomme:  Traite  Pract.  et  Elem.  de  Path.  Syph.,  Paris,  1864. 
"  Zeissl,  von:  Comp.  d.  Path.  u.  Therap.  d.  prim.  Syph.  u.  einf.  ven.  Krank.,  Vienna, 
1850. 

"  Diday:  Mai.  Ven.  et  Cutanee,  Paris,  1876,  p.  4. 
i«  Duyon:  Mai.  Ven.  et  Cutanea,  Paris,  1876,  p.  4. 


HISTORIC  31 

no  difference,  just  as  virulent  a  urethritis  being  caused  by  an  infinitesi- 
mal amount  as  by  a  large  quantitj'.  These  facts  were  strong  argu- 
ments for  the  viruhsts,  and  as  time  went  on  this  faction  grew  stronger. 
The  work  of  Koch,  Halher,'  Belhomme  and  Martin,-  Pasteur,  and 
Klebs  began  to  make  itself  felt,  and  the  younger  and  more  scientific 
men  turned  to  the  laboratory  in  the  hope  of  finding  there  the  proof  that 
would  end  this  lengthy  discussion. 

In  1658  a  Jesuit,  Athenasius  Kircher,^  described  "vermiculi"  in 
the  pus  from  syphilitics,  but  what  he  saw  were  probably  pus-  or  blood- 
cells,  which  up  to  this  time  had  not  been  discovered.  Deidier,^  in  1710, 
beUeved  syphilis  to  be  due  to  the  presence  of  small  maggots:  "These 
hatch  and  produce  others,  and  in  this  way  we  can  assume  the  propaga- 
tion of  the  venereal  virus.  How  otherwise  can  the  fact  be  accounted 
for  that  pox  could  be  carried  from  the  Orient  into  Europe  and  then 
pass  by  commerce  with  a  single  prostitute  into  the  French  army  and 
thus  to  France,  unless  by  these  venereal  worms  which  are  constantly 
laying  great  numbers  of  ova?"  "So  naive  the  conception  and  so  cor- 
rect is  the  chain  of  thought  devised  that  this  man  divined  what  could 
not  be  proven  until  two  hundred  years  later"  (Finger). 

Some  authorities  believed  that  the  Marseilles  epidemic  of  1721 
was  caused  by  animalcula.  Five  years  later  a  satire  appeared  in 
Paris  that  threw  ridicule  upon  the  entire  subject.  Certain  parasites 
which  he  called  the  "Vibrio  lineoa"  and  the  "Trichomonas  vaginalis," 
and  which  he  discerned  in  gonorrheal  leukoi-rhea,  were  described  by 
Donne'  in  1837.  For  some  time  these  organisms  held  the  field  as  the 
cause  of  vaginitis,  but  seven  years  later  we  find  Donne  of  the  oi^inion 
that  gonorrheal  pus  differs  in  no  respect  from  ordinary  pus,  and  that 
the  "Trichomonas"  which  he  had  described  were  the  inhabitants  of 
the  normal  vaginal  secretion. 

At  about  this  period  the  erroneous  view  became  prevalent  that  tlic 
vagina  was  the  chief  seat  of  gonorrhea  in  women.  If  the  urethra  and 
liladder  were  not  macroscopically  involved,  and  if  no  gross  changes 
were  found  in  the  vagina,  the  surgeons  of  the  day  were  inclinetl  to 
give  the  patient  a  clean  bill  of  health  so  far  as  gonorrhea  was  concerned. 
In  fact,  gonorrhea  in  women  was  looked  upon  as  a  comparatively  in- 
significant disease.     Cervicitis,  endocervicitis,  and  uterine  lesions  were 

'  lliillicr:  Zcit.schrift  f.  Panusitcnk.,  1S72. 

•  Holliomtiic  iiiul  Martin:  Trait<!  I'ract.  ct  lOlctn.  lic  I'atli.  Sy|)li.,  I'aris,  IStil. 

•  Kirrher:  .Scrutinium  Physico-mcdiciiim  C'onla({ionc.>(  liiis,  (iiiac  postis  dicitiir,  i-tc, 
Rome,  ie.')8. 

'  Dcidicr:   Vim.  Med.  S.  L.  Maladies  Vcnpricnnrs,  I'aris,  1710,  p.  l:{. 
'Doiinc:    Hrch.  .Micr.  s,  1.  Nalur.  d.  Mucus  r.  1.  Maticr  d.  divers  Kcoul.  d.  Orijaii. 
lienito-uriii.,  etc.,  I'aris,  ls:{7,  also  ( 'ours  d.  .Micros.,  ISl  1,  p.  201. 


32  GONORRHEA    IN    WOMEN 

classed  as  uterine  catarrh,  a  condition  believed  to  be  quite  separate 
and  distinct  from  gonorrhea.  By  only  a  few  observers  had  the  con- 
nection between  pelvic  peritonitis  and  gonorrhea  been  even  hinted  at. 
It  requires  but  Uttle  imagination  to  grasp  the  vast  social  importance 
of  this  mistaken  viewpoint  of  the  pathology  of  gonorrhea.  In  the  male, 
pus  was  regarded  as  the  infective  agent,  and  while  this  was  present  in 
a  urethritis,  intercourse  was  interdicted.  The  opinion  advanced  by 
Lee,  that  "so  long  as  any  discharge  exists,  sexual  congress  is  unsafe," 
was  not  generally  accepted,  and  may  be  looked  upon  as  representing 
the  most  advanced  view  of  this  period.  "Not  only  does  the  medical 
world  believe  that  a  so-called  cured  gonorrhea  is  actually  cured,  but 
they  are  even  of  the  opinion  that  a  man  who  has  a  gleet  (Nachtripper) 
may  not  infect  his  wife.  It  is  usual,  at  the  present  time,  among  the 
best  informed  practitioners  (non-specialists),  to  sanction  marriage  in 
the  case  of  men  who  still  continue  to  observe  adhesions  of  the  urethral 
orifice  and  staining  of  the  linen,  as  beaux  restes  of  a  gonorrhea.  Even 
the  highest  authorities,  as  Professor  A.  Geigel,^  permit  the  cohabita- 
tion with  the  newly  married  wife  of  a  man,  the  subject  of  gleet,  so  soon 
as  the  urethral  discharge  appears  perfectly  clear"  (Noeggerath^) . 
This  quotation  has  been  introduced  in  full,  as  it  exemplifies  so  thor- 
oughly the  general  opinion  of  the  medical  profession  regarding  the 
contagiousness  of  gonorrhea  at  this  period. 

In  1872  Emil  Noeggerath,'  a  German  physician  and  former  prac- 
titioner in  New  .York,  published  a  work  on  gonorrhea  that  was  destined 
to  revolutionize  the  view  of  the  medical  world  regarding  the  clinical 
significance  of  the  disease,  more  especially  of  gonorrhea  in  the  female. 
Unfortunately  for  English  readers  this  treatise  was  published  in 
German  and  has  never  been  translated.  This  may,  in  part,  account 
for  the  slow  recognition  which  this  epoch-making  monograph  received. 
This  writer's  views  regarding  gonorrhea  were  in  some  respects  exag- 
gerated, and,  like  many  another  man  in  a  similar  position,  these 
portions  of  his  paper  were  widely  quoted  and  branded  as  false,  whereas 
the  wide-reaching  and  accurate  clinical  observations  were  allowed  to 
pass  more  or  less  unnoticed.  Noeggerath  was  the  first  to  insist  that 
inflammation  of  the  uterus  and  appendages  was  the  direct  result  of 
gonorrhea,  and  that  gonorrhea  was  extremely  intractable  to  treat- 
ment; that  it  often  remained  latent  for  months  or  years  before  causing 
severe  complications,  and  that  infection  the  result  of  sexual  intercourse 
might  result  after  long  periods  of  quiescence.     Of  this  he  writes:   "Of 

'  Geigel:  Geschich.  Path.  u.  Therap.  d.  Syph.,  Wurzburg,  1867,  p.  73. 

^  Noeggerath,  Emil:   Die  latente  Gonorrhoe  in  weib.  Geschlecht,  Bonn,  1S72. 

'  Noeggerath:  Loc.  cit. 


HISTORIC  33 

one  hundred  women  who  become  the  wives  of  men  who  have  formerh' 
been  afflicted  with  gonorrhea,  scarcely  ten  remain  healthy.  The  rest 
suffer  from  one  of  the  ailments  which  it  is  the  task  of  this  treatise  to 
describe."  To  bear  out  these  conclusions  he  presents  notes  of  50 
selected  cases.  His  classification  of  intraperitoneal  pelvic  gonorrhea — 
into:  (1)  Acute  perimetritis;  (2)  recurrent  perimetritis;  (3)  chronic 
perimetritis;  and  (4)  oophoritis — was  undoubtedly  faulty.  Never- 
theless his  conception  of  the  nature  of  gonorrhea  was  correct;  thus  he 
says:  "A  woman  who  at  any  time  in  her  life  has  had  an  acute  gon- 
orrhea has  to  expect  at  some  more  or  less  distant  period — it  may  be  a 
month  or  a  year — a  subsequent  attack  of  peritonitis  in  some  form,  and 
that  the  wife  of  a  man  who  has  ever  suffered  from  gonorrhea  is,  with 
regard  to  an  attack  of  perimetritis,  in  the  same  position  as  if  she  her- 
self had  had  an  acute  gonorrhea."  He  dwells  strongly  on  this  point, 
and  goes  on  to  say:  "The  young,  hitherto  healthy  wife,  begins  to 
complain  a  few  weeks  after  marriage.  Menstruation  commences  to 
be  more  profuse  than  formerly,  accompanied  by  dysmenorrhea. 
Leukorrhea  becomes  more  or  less  excessive,  especially  after  the  periods. 
This  gradually  increases,  ultimately  becoming  continuous  without  in- 
termission until  the  next  menstruation  begins.  After  a  few  months 
severe  pain  commences  in  either  or  both  sides  of  the  pelvis,  and  the 
sufferer  is  ultimately  compelled,  on  account  of  fever  and  unbearable 
burning  pains  in  the  abdomen,  with  increased  leukorrhea,  to  take  to 
her  bed  and  send  for  medical  assistance.  According  to  the  severity  of 
her  attack  she  remains  confined  to  her  bed  for  weeks  or  perhaps  for 
months,  with  exhaustetl  strength,  struggling  for  life,  ultimately  re- 
covering, but  remaining  sterile  and  invalided  for  the  remainder  of  her 
days."  Noeggerath  points  to  the  freciuency  with  which  sterility 
follows  gonorrheal  infections  in  women,  and  shows  that  when  preg- 
nancy does  occur,  the  sub.sequent  labor  is  often  followed  by  sepsis. 
There  can  be  no  doubt  that  during  this  period  gonorrhea  was  extremely 
prevalent  in  New  York.  Nevertheless,  the  statement  of  Noeggerath, 
that  80  per  cent,  of  married  men  have  had  gonorrhea  at  some  time 
during  their  lives,  that  90  per  cent,  of  these  are  uncured,  and  lliat  (id 
per  cent,  of  all  married  women  have  been  infected  with  gonorrhea, 
seems  to  be  the  view  of  a  pessimist.  The  conclusions  he  arrived  at  in 
this  masterly  essay  are  as  follows: 

1.  (ionorrliea  in  the  man,  as  well  as  in  tlic  woman,  persists  for  the 
whf)le  lifetime,  in  spite  of  api)arent  cure. 

2.  Latent  gonorrhea  occurs  in  man  as  well  as  in  woiiiaii. 

■?.   Latent   gonorrhea   in  1  he  man,  as  well  as  in   tlic  unman,  may 


34  GONORRHEA    IN    WOMEN 

evoke  in  a  hitherto  liealthy  individual  either  a  latent  or  an  acute 

attack. 

4.  Latent  gonorrhea  in  the  woman  manifests  itself  m  the  course  ot 
time  by  perimetritis,  acute,  chronic,  or  recurrent,  or  by  oophoritis,  or  as 
a  catarrh  of  some  definite  portion  of  the  genital  mucous  membrane. 

5.  The  wives  of  men  who  at  any  time  in  their  lives  have  had  gon- 
orrhea are,  as  a  rule,  sterile. 

6.  Such  women,  if  they  do  become  pregnant,  either  abort  or  bear 
but  one  child.     Only  very  exceptionally  are  more  born. 

7.  From  the  discharge  of  a  woman  affected  with  latent  gonorrhea  a 
fungus  may  be  cultivated  that  is  analogous  to  that  obtained  from  the 
discharge  of  acute  gonorrhea. 

Noeggerath  lived  to  modify  his  views  regarding  the  prevalence  and 
incurability  of  gonorrhea.  It  is  certain  that  he  strongly  suspected  the 
nature  of  the  etiologic  factor  of  gonorrhea,  and  that  had  he  been 
famiUar  with  Koch's  methods  of  investigating  microorganisms,  Neis- 
ser's  discovery  might  have  been  anticipated  by  seven  years.  In  the 
year  following  the  appearance  of  Noeggerath 's  work  Macdonald' 
published  a  paper  strongly  confirming  the  views  of  the  former.  But 
with  the  caution  for  which  his  countrymen  are  noted,  Macdonald 
hesitated  to  confirm  all  Noeggerath'«  extreme  opinions.  In  writmg 
of  the  etiology  of  gonorrhea,  Macdonald  made  this  prophetic  state- 
ment: "It  does  not  seem  in  the  least  Utopian  to  anticipate  that  some 
day  we  shall  be  able  to  see  with  the  microscope  the  germs,  whether 
they  be  one  or  many  species,  which  give  rise  to  the  blood  changes 
which  give  rise  to  puerperal  fever  and  other  septicemic  disorders." 

In  reviewing  the  history  of  gonorrhea,  there  are  three  men  whose 
names  stand  out  above  all  others.  The  first  of  these  is  Ricord,  who 
definitely  established  the  identity  of  gonorrhea,  and  thus  placed  its 
treatment  and  that  of  syphilis,  with  which  it  had  previously  been  con- 
founded, upon  a  sound  basis.  The  second  great  advance  in  the  study 
of  this  disease  is  due  to  the  epoch-making  monograph  of  Noeggerath. 
The  latter's  work  was  strictly  chnical;  to  him  we  are  indebted  for 
estabhshing  the  relationship  existing  between  pelvic  peritonitis  and 
gonorrhea,  for  pointing  out  the  long-continued  contagiousness  of  this 
disease,  its  latency,  and  its  devastating  results  with  regard  to  sterility 
and  puerperal  infection.  The  third  name  in  this  great  triad  is  that 
of  Neisser.  Noeggerath  was  fortunate  in  having  Neisser's  discovery 
come  when  it  did,  for  it  enabled  him  to  confirm  his  clinical  work 
by  exact  laboratory  researches.  As  Bumm  has  happily  remarked, 
"Noeggerath  was  more  fortunate  than  Semmelweis:   he  lived  to  see 

>  Macdonald,  Angus:  Edinburgh  Med.  Jour.,  June,  1S73. 


HISTORIC  35 

the  triumph  of  his  observations.  For  this  he  has  to  thank  Neisser, 
who  soon  after  discovered  the  gonococcus  and  made  possible  the  cer- 
tain proof  of  his  statements  relative  to  the  frequency'  of  the  lesion." 

Early  in  1872  Hallier'  reported  the  finding  of  a  micrococcus  in 
gonorrheal  pus.  Some  of  these  cocci  were  free  and  others  were  intra- 
cellular. Owing  to  insufficient  laboratory  facihties,  such  as  staining, 
illuminating,  and  magnifying,  these  results  attracted  Uttle  attention, 
and  to  Neisser,^  seven  j-ears  later,  is  very  properly  attributed  the  honor 
of  the  discoverj'  of  the  gonococcus. 

Another  name  that  has  been  more  or  less  overlooked  in  tliis  con- 
nection is  that  of  Salisbury ,5  who,  in  1868,  stated  that  for  six  years  he 
had  been  examining  the  urethral  discharges  from  cases  of  urethritis. 
Salisbury  writes :  "I  had  not  been  pursuing  this  mode  of  inquiry  long 
before  I  discovered  spores  which  were  scattered  about  free  in  the  pus 
and  in  the  epithefial  cells.  .  .  .  These  spores  are  very  minute 
and  well  defined;  they  are  often  discovered  in  twos  and  sometimes 
in  fours.  ...  In  some  instances  the  pus-cells  become  filled  with 
the  spores."  This  observer  obtained  his  material  for  examination  by 
scraping  the  urethra.  It  seems  that,  undoubtedly,  he  really  saw  the 
gonococci,  but  failed  to  receive  proper  recognition  through  lack  of  proper 
staining  methods.  He  also  described  filaments  which  he  believed  re- 
sulted from  the  "spores."  He  believed  that  every  drop  of  gonorrheal 
pus  contained  specific  poison.  His  illustrations,  while  showing  some 
of  the  spores  in  pairs,  present  others  that  appear  in  groups,  without 
definite  pair  formation.     His  description  is,  however,  convincing. 

On  July  12,  1879,  Albert  Neisser,  at  that  time  an  assistant  in  the 
University  Clhnic  of  Dermatology  at  Breslau,  described  a  micrococcus 
that  he  believed  to  be  the  cause  of  gonorrhea.  His  conclusions  were 
drawn  from  the  study  of  35  cases.  In  only  one  case  of  urethritis  in 
the  male  was  the  micrococcus  not  found,  and  this  case  was  suspected 
from  the  first  of  being  one  of  urethral  chancre.  In  9  cases  of  urethritis 
in  the  female  the  micrococcus  was  found  in  all.  It  was  also  demon- 
strated in  7  cases  of  purulent  ophthalmia.  Control  examinations  were 
made,  but  in  no  case  was  the  micrococcus  discovered.  To  demon- 
strate these  micrococci  Neisser  employed  the  method  of  Koch.  A  small 
drop  of  pus  was  spread  thinly  over  a  cover-glass  and  allowed  to  dry. 
It  was  then  stained  with  an  aqueous  solution  of  methyl-violet  and 
again  put  aside  until  dry.  Neisser  described  the  micrococci  and  their 
method  of  division  accurately.     This  discovery,  coming  as  it  did  at 

'  Ilallier:  Zeitschr.  f.  Piiriisitciik.,  1S72. 

-  .\eis.ser:  Cent.  f.  d.  nied.  \Vis.ioii.,  July  12,  1879. 

'  SalLslmry,  .J.  H.:  .\iiicr.  .lour.  Mc<l.  .Sci.,  1SG8,  pp.  17-25. 


3Q  GONORRHEA    IN    WOMEN 

a  time  when  the  Germans  were  so  confidently  expecting  great  results 
from  the  new  era  of  bacteriology  introduced  by  Koch,  attracted  uni- 
versal attention,  and  many  investigators  immediately  took  the  field. 
Cheynei  reported  that  in  1879  he  had  discovered  the  gonococcus. 
Unfortunately,  his  publication  did  not  appear  until  July  24,  1880. 
In  1880  Weis  observed  gonococci  in  the  pus  from  35  cases  of  urethritis. 
In  only  one  case  of  urethral  discharge  were  the  gonococci  not  found, 
and  this  proved  later  to  be  a  case  of  urethral  chancre.     He  endeavored 
to  find  gonococci  in  the  leukorrhea  from  35  cases,  but  failed  in  every 
instance.     In  1882  Neisser-  pubUshed  a  second  paper,  in  which  he 
confirmed  nearly  all  his  previously  published  views.     He  insisted  that 
the  micrococcus  previously  described  by  him  differed  functionally  and 
morphologically  from  all  other  organisms.     He  showed  that  the  gono- 
cocci could  be  cultivated  on  artificial  media,  and  that  he  himself  had 
grown  them  for  seven  generations  on  cultures  made  from  meat  extract, 
peptone    and  gelatin  of   neutral   reaction.      Numerous   experiments 
that  he  made  on  lower  animals  all  failed.     From  1879  to  1886,  or  even 
later,  the  literature  relating  to  the  gonococcus  is  extremely  abundant. 
Thus  Bumm^  mentions  that  there  were  52  contributions  on  this  subject 
up  to  the  beginning  of  1886,  and  Sinclair^  found  40  papers  on  ophthal- 
mia neonatorum  alone  abstracted  in  the  Centralblatt  fiir  Gynakologie 
from  1881  to  1886.     As  might  have  been  expected,  all  Neisser's  con-, 
elusions  were  "not  immechately  accepted.     Even  so  late  as  1890  con- 
siderable doubt  still  existed  in  the  minds  of  many  investigators  regard- 
ing the  role  played  by  the  gonococcus  in  the  production  of  gonorrhea. 
Bokai  and  Finkelstein"  (1880)  found  micrococci  constantly  present 
in  gonorrheal  pus  and  in  the  secretion  of  ophthalmia.     They  made 
cultures,  and  from  these  inoculated  the  urethras  of  6  medical  students. 
Of  these,  3  developed  gonorrhea.     In  1  of  the  3  negative  cases  the 
urethral' discharge  was  found  to  contain  oil  of  eucalyptus,  which  is 
toxic  to  gonococci.     In  the  other  2  cases  the  failures  were  probably 
due  to  faulty  technic.     During  this  year  (1880)  further  confirmatory 
work  appeared  from  Ehrlich,'^  Rucker,'  Aufrecht,**  and  Gaffky.     In 

1  Cheyne:  Brit.  Med.  Jour.,  July  24,  1880,  p.  114. 

2  Neisser,  A. :  Deut.  med.  Wochenschr.,  1882,  vol.  xiii,  p.  279. 

3  Bumm:  Beit.  z.  Kenntniss  d.  Gonococcus,  Wiesbaden,  1885;  also  Der  Mikr 
organismufd.  gonorrhoischen  Schleimhaut-Erkrankungcn,  Gonococcus  Neisser,  secon. 
edition,  Wiesbaden,  J.  F.  Bergmann,  188/.  ,     ,,    ,         jc 

«  Sinclair,  N.  J.:  On  Gonorrheal  Infections  in  Women,  in  Wood  .s  Med.  and  hurg 
Monographs,  1889,  vol.  i. 

-'  Bokai  and  Finkelstein;  Orvosi  Helilap,  May  16,  1880;  also  Pester  Med.-Clur.  Presse 
June  20,  1880. 

«  Ehrlieh:  Zeit.  f.  klin.  Med.,  1881,  vol.  ii,  p.  70. 

'  Rucker:  Deutsch.  med.  Wochenschr.,  1880. 

»  Aufrecht:  Path.  Mittheil.,  Magdeburg,  1884,  p.  147. 


HISTORIC  37 

1881  Hirschljerg  and  Krouse^  found  the  gonococcus  in  all  cases  of  oph- 
thalmia neonatorum  examined,  but  claimed  to  have  discovered  mor- 
phologically similar  micrococci   in   the  vaginal  secretion  of  healthy 
women.     Haab-  also  found  the  gonococcus  present  in  the  pus  from  a 
large  series  of  cases  of  ophthalmia  neonatorum.     Slatter^  and  Langle- 
berf  confirmed  Neisser's  conclusion.     In  1882  Leistikow/  an  assist- 
ant in  the  clinic  for  syphilis  in  the  Berlin  Charite  Hospital,  studied 
gonococci  in  the  discharges  from  200  cases  of  urethritis,  3  cases  of 
ophthalmia  in  adults,  and  4  eases  in  children.     As  a  result  of  his  in- 
vestigation this  writer  came  to  the  conclusion  that  the  microscopic 
demonstration  of  the  presence  of  the  gonococci  absolutely  proved  the 
character  of  the  infection.     Krouse«  (1882)  and  Konigstein"  (1882) 
experimented  by  means  of  cultures  and  inoculations.     In  almost  all 
cases   in   which   cultures  were  inoculated  into  the  eyes  of  animals, 
negative  results  were  obtained.     Konigstein  did  not  agree  with  Neisser 
in  believing  that  the  diplococcus  was  characteristic  of  a  gonorrheal  in- 
flannnation  of  a  mucous  membrane.     Ecklund^  asserted  that  he  found 
gonococci  in  the  secretions  from  cases  of  stomatitis,  chronic  enteritis, 
and  even  of  inflammation  of  the  lungs.     It  is  very  evident,  from  his 
paper,  that  his  conclusions  were  drawn  as  much  from  his  imagination 
as  from  fact.     In  the  following  year  (1883)  Bockhart,'  of  Wurzburg, 
accurately   demonstrated   for  the  first  time  the  pathologic  changes 
produced  by  the  gonococcus.     With  a  pure  culture  of  this  micrococcus 
he  inoculated  the  healthy  urethra  of  a  forty-six-year-old  male  paralytic, 
whose  death  was  daily  expected.     Two  days  after  the  injection  of  the 
gonococci  the  meatus  became  red  and  swollen,  and  by  the  sixth  day 
a  well-developed  purulent  urethi-itis  was  present.     This  increased  in 
.severity  until  the  twelfth  day,  wli(>ii  the  patient  died.     From  the  thirtl 
day  following  the  inoculation  gonococci  in  pure  culture  were  secured 
daily  from  the  urethral  discharge.     From  a  microscopic  examination 
of  the  tissues  of  the  urethra  Bockhart'"  concluded  that  the  gonococci 
penetrated  between  the  epithelial  cells  into  the  lymph-spaces  of  the 
mucosa  and  subnnicosa  of  the  fossa  navicularis,  and  that  they  here 

'  Hirsriibcrg  aiiij  Krousc:  Cent.  f.  pnikt.  Augpiihoilk.,  1881,  vol.  v,  p.  39. 
'Haab:  (Vnt.  f.  piakt.  .VuKcnhoilk.,  Soptombcr,  ISSl;  Corrrspomlonzl)!.  f.  Scliwii/.cr 
Aerztc,  vol.  ii,  p.  SO,  I'"cstsflir.,  Wirabaclcn, 

'Slatlcr:   Sili!iiii«shcr.  d.  XIV.  Ophllial.  (Icscllscli.  in  Ihuh-Wwvii.  pp.  0,  .")1. 

'  LanRlf'fjcrt:   M.-iladics  vcncricniics,  Paris,  ISdt,  p.  Id. 

'Lewtikow:  Charil(;-,\niialcn,  Berlin,  18S2,  vol.  vii,  p.  7.")0. 

'  Krousn:  Cent.  f.  .VuRcnhoilk.,  1882. 

"  KoiiiK.slcin:  Vorlrag,  nclialt.  in  d.  K.K.  Gesoll.  d.  Aerzte,  Vienna. 

I  ikliind:  Aiinal.  d.  Dermal.,  Pari.s,  1882,  vol.  iii,  p.  .540. 
'  liockharl,  .M.:   Viertelj.  f.  Dermat.  u.  Syph.,  Vienna,  188:5,  vol.  x,  p.  .3. 
'"Bockliart:  Sil/.uiin.slMriclil  il.  pliy.s.  mod.  Ge.sellschaft  zu  WiirzImrK,  18S.S,  No.  1. 


38  GONORRHEA    IN   WOMEN 

multiplied  and  set  up  a  leukocytosis;  that  the  gonococci  entered  the 
white  blood-corpuscles,  and  were  thus  disseminated  to  various  tissues. 
Young'  has  questioned  the  correctness  of  the  bacteriologic  diagnosis 
of  this  case. 

Bockhart  also  published  a  report  demonstrating  the  presence 
of  gonococci  in  the  discharges  of  258  cases  of  chronic  urethritis. 
Four  years  later  (1886)  Bumm  gives  the  following  description  of 
the  histologic  picture  produced  by  the  gonococcus,.  and  its  means 
of  dissemination  from  the  surface  to  the  deeper  layers:  The  in- 
fecting secretion  conveys  a  certain  number  of  gonococci  to  the 
mucous  membrane.  These  penetrate  the  layers  of  epithelial  cells, 
and  reach  the  papillary  body  of  the  mucous  membrane,  passing 
through  and  between  the  protoplasm  and  cement  substance  of  the 
epithelial  elements.  Swarms  of  white  blood-corpuscles  emigrate  at 
this  time  from  the  dilated  capillary  network,  which  extends  almost  to 
the  epithelial  covering,  and  penetrate  into  the  upper  stratum  of  the 
connective  tissue,  whence,  laden  with  gonococci,  they  pass  through 
the  epithelium  to  the  surface.  The  epithelial  stratum,  whose  firmness 
is  destroyed  by  the  proliferation  of  cocci,  becomes  fissured  by  the 
stream  of  fluid  accompanying  them  and  rises  in  clumps;  this  process 
may  be  aided  by  capillary  hemorrhages  between  the  epithelium  and 
cellular  tissue.  The  distribution  of  the  cocci  is  confined  to  the  super- 
ficial laj^ers  of  the  subepithelial  cellular  tissue,  where  they  are  arranged 
between  the  fibers  in  rows  or  round  colonies.  While  the  micrococci 
increase  in  this  manner  in  the  outermost  layers  of  the  connective  tissue, 
the  inflammatory  symptoms  increase  in  intensity,  and  the  round-cell 
infiltration  finally  occupies  the  entire  papillary  body,  cell  being  closely 
applied  to  cell.  This  furnishes  the  transition  to  the  purulent  stage, 
in  which  the  majority  of  the  gonococci  are  washed  away  by  the  abun- 
dant suppuration.  After  a  variable  time  regeneration  begins  to  take 
place  from  the  remains  of  the  original  epithelium,  and  by  its  extension 
puts  an  end  to  the  further  spread  of  the  cocci  in  the  tissue,  whereas 
the  migration  of  the  pus-cells,  which  carry  off  the  remainder  of  the  cocci, 
proceeds  uninterruptedly.  With  the  regeneration  of  the  epithelium 
are  usually  associated  proliferating  processes,  from  the  lowermost 
layers  of  which  epithelial  papilliE  grow  into  the  connective-tissue  sub- 
stratum. At  this  time  the  cocci,  with  the  aid  of  the  pus-cells,  have 
disappeared  from  the  papillary  bodies,  and  are  found  only  in  the  upper 
layers  of  the  epithelial  covering.  But  if  the  fresh  epithelial  covering 
cannot  withstand  an  invasion  of  migrating  round  cells  induced  by 

'Young,  H.  H.:   The  Gonococcus:   Report  of  Successful  Cultivations,  Contributions 
to  the  Science  of  Medicine,  dedicated  by  his  pupils  to  W.  H.  Welch,  Baltimore,  1900,  p.  677. 


HISTORIC  39 

external  irritants,  its  continuity  will  suffer,  and  a  new  lesion  of  the 
papillary  body  produced  by  cocci  will  take  place — i.  e.,  a  relapse  occurs. 
During  the  latter  part  of  the  purulent  stage  and  during  the  entire 
mucopurulent  stage  the  proUferation  of  gonococci  takes  place  outside 
of  the  tissues,  upon  the  surface  of  the  epithelium  and  in  the  secretion. 
Corroborative  evidence  of  the  etiologj^  of  gonorrhea  and  ophthal- 
mia neonatorum  appeared  at  about  this  time  (1882)  from  the  pen  of 
Eschbaum,^  Newberry,-  Bareggi,  jNIarchiafava,'  Campona,  and  Kej'- 
ser.''  The  last  of  these  writers  examined  the  urethral  discharge  from 
64  cases  of  urethritis, — 30  whites  and  34  negroes, — and  found  the 
gonococcus  in  all.  They  were  absent  in  3  other  cases,  2  of  which  had 
been  treated,  and  in  the  third  little  discharge  was  obtainable.  In 
1883  Sternberg"  appears  to  have  mistaken  the  Micrococcus  catarrhalis 
for  the  gonococcus,  and  as  a  result  denied  the  specific  character  of  the 
latter.  Welander*  examined  144  cases  of  urethritis  in  the  male  and 
79  in  the  female,  and  demonstrated  the  presence  of  gonococci  in  all. 
He  also  performed  the  following  experiment:  He  utilized  3  women 
suffering  from  urethritis,  but  in  whom  the  vaginal  secretion  was  free 
from  gonococci.  He  inoculated  the  vaginal  discharge  from  these  sub- 
jects into  the  urethras  of  3  men.  None  of  these  contracted  gonorrhea; 
later  these,  and  a  fourth  individual,  were  exposed  to  the  secretion  from 
the  urethra  from  the  same  women.  Gonorrhea  resulted  in  all.  In  21 
confrontations,  gonococci  were  found  in  both  partners.  Additional 
confirmatory  proof  of  Neisser's  discoveries  was  obtained  by  Cham- 
eron,^  Wyssokowich  and  Belleli,*  the  last  named  making  his  investi- 
gations in  an  examination  bureau  for  prostitutes.  In  1884  an  im- 
portant series  of  experiments  were  conducted  by  Zweifel.^  The  lochia 
from  6  normal  cases,  having  first  been  found  to  be  microscopically  free 
from  gonococci,  was,  with  certain  precautions,  inoculated  into  the  eyes 
of  healthy  infants.  In  none  did  ophthalmia  neonatorum  result. 
This  observer  therefore  believed  that  only  lochia  containing  gonococci 
could  cause  ophthalmia  neonatorum.  Ikinnn"'  reported  having  con- 
stantly found  gonococci  in  the  lochia  of  mothers  whose  infants  suffered 

'  Kschbaum;  Deut.  mod.  \\'och.,  Berlin,  Manh,  lS,s:j,  p.  1S7. 
'  Xewbcrry:  Maryland  McmI.  Jour.,  1SS2,  vol.  ix,  p.  481. 
'  Marchiafava:  Gazz.  dogli  Ospod.,  ann.  3,  Xo.  21. 
*  Keysor:  Maryland  Med.  .lour.,  1SS2,  vol.  ix,  p.  481. 
'  .SternhiTR:  Med.  News,  Phila.,  1883,  vol.  xlii,  pp.  07,  96. 
"  Welandcr:  Monats.  f.  prakt.  Dermat.,  1884,  vol.  iii,  p.  12.5. 
'  (Uiameron:  Th&se  de  Paris,  1884,  No.  346,  pp.  3.5,  37. 
'Bellcli:    Unione  Med.   Iviui.s.,   Alexandria.    18S4,    1,   No.   S. 
»  Zweifel:  Areli.  f.  Clyn.,  1884,  vol.  xxii,  p.  31S. 

'"Bumm:     Dor  Mikro-oruani.smus   der    Ronorrlioi.sehen    SclileindiMUt-lJkrankiinKen, 
Gonoeoeeus  Neisser,  second  edition,  Wiesbaden,  1887. 


40  GONORRHEA    IN    WOMEN 

from  ophthalmia  neonatorum.  Arning/  working  in  Neisser's  cUnic, 
discovered  gonococci  in  the  pus  from  Bartholinian  abscesses  in  8 
cases  of  gonorrhea.  Kammerer-  claims  to  have  found  gonococci  in 
the  fluid  of  gonorrheal  arthritis.  Aubert^  found  the  gonococcus  in  200 
cases  of  suspected  gonorrhea,  and  believed  that  this  organism  was  the 
most  frequent  cause  of  urethritis.  Gama  Pinto'*  denied  the  specific 
character  of  the  gonococcus,  declaring  that  he  found  morphologically 
similar  micrococci  in  the  pus  from  various  conditions.  As  the  result  of 
a  study  of  92  cases  of  ophthalmia  neonatorum  Kroner^  came  to  the 
conclusion  that  there  were  two  forms  of  ophthalmia — one,  caused  by 
the  gonococcus,  and  the  other,  the  result  of  a  bacterium.  He  also  found 
gonococci  present  in  the  lochia  from  18  out  of  21  mothers,  whose  in- 
fants suffered  from  ophthalmia  neonatorum.  Paul  published  a  paper 
proclaiming  the  virulence  of  the  gonococcus.  Icard''  (1884)  describes 
cases  of  urethritis  due  to  microorganisms  other  than  gonococci. 
Sanger'  stated,  before  the  German  Natural  Science  and  Medical  As- 
sociation of  Magdeburg,  in  1884,  that  the  hope  aroused  by  Neisser 
that  the  gonococcus  would  be  the  means  of  diagnosticating  chronic 
gonorrhea  had  proved  vain.  He  believed  that  it  was  an  established 
fact  that  gonorrhea  might  exist  without  the  presence  of  gonococci 
being  demonstrable.  He  went  further,  and  stated  that,  in  view  of  the 
occurrence  of  non-pathogenic  forms  of  diplococci,  the  presence  of  the 
gonococcus  did  not  prove  the  gonorrheal  nature  of  the  disease.  Fran- 
keP  also  believed  that,  as  there  were  various  forms  of  cocci  in  the  geni- 
tal secretions  of 'the  female,  culture  and  inoculation  were  the  surest 
means  of  differentiating  their  clinical  nature.  Widmark^  examined  13 
cases  of  purulent  ophthalmia,  12  in  infants  and  1  in  an  adult.  In  the 
secretion  from  10  of  these  gonococci  were  found.  In  2  cases  of  ure- 
thritis in  young  girls  in  which  gonococci  were  demonstrated  the  parents 
had  gonorrhea,  and  in  the  urethral  secretion  of  both  mothers  gonococci 
were  found.  Oppenheimer^"  studied  the  influence  of  various  gonococ- 
cids  upon  pure  cultures  of  gonococci.  Lundstroem"  (1885)  examined 
the  discharges  of  50  cases  of  acute  and  chronic  urethritis  and  found 
gonococci  in  all.     Similar  results  were  obtained  by  Kries  (1885). 

'  Arning,  E.:  Vierteljahressohr.  f.  Derm.  u.  Syph.,  1884,  vol.  x. 

2  Kammerer:  Cent.  f.  Chir.,  1884,  No.  4.  '  Aubert:  Lyon  mc'nl.,  .Inly  Ki,  1884. 
<  Pinto:  Med.  Contemp.,  June  8  and  15,  1885. 

'  Kroner:  Amer.  Jour.  Bact.,  1885,  vol.  viii,  p.  197. 

0  Icard:  Lyon  m<^d.,  1884,  No.  81.  '  Sanger:  Arch.  f.  Gyn.,  1884,  vol.  xxv,  1. 

«  Frankel:  Dcut.  mcd.  Wooh.,  1885,  No.  2. 

3  Widmark:  Aich.  f.  Kinderheilk.,  1885,  No.  7. 
'°  Oppenheimer:  Aroh.  f.  Gyn.,  vol.  xxv,  No.  1. 

"  Lundstroem:    Studier  Ofver  Gonoc.   (Neisser),   Holsingfors,  1885;  also  Monats.  f. 
prakt.  Derm.,  188.5,  vol.  iv,  p.  4.55. 


HISTORIC  41 

Cseri/  of  Budapest,  reports  that  from  1883  to  the  date  of  the  ap- 
pearance of  his  paper  (1885),  the  discharge  from  26  children  suffering 
from  contagious  colpitis  had  been  examined  microscopically,  and  a 
large  diplococcus,  similar  to  Neisser's  gonococcus,  had  been  found 
in  nearl}^  all  cases.  This  discharge,  when  inoculated  into  the  eye, 
produced  an  ophthalmia.  The  same  writer  relates  the  case  of  a  near- 
sighted nurse  who,  while  douching  one  of  these  children,  accidentally 
introduced  some  of  the  vaginal  discharge  into  her  eye.  An  ophthalmia 
followed  that  resulted  in  the  loss  of  the  organ.  Frankel-  also  found, 
in  the  vaginal  discharge  of  children,  diplococci  which  he  described  as 
identical  with  the  gonococci  of  Neisser,  and  he  believed  these  children 
to  be  free  from  gonorrhea.  An  excellent  review  of  the  French  literature 
relating  to  the  gonococcus  was  published  by  Martineau^  in  1885.  He 
claims  for  Bouchard  precedence  by  one  year  in  the  discover}^  of  the 
gonococcus.  His  arguments  are,  however,  unconvincing,  and  no 
proof  is  brought  forward  to  substantiate  the  claim.  During  this  year 
(1885)  further  confirmatory  evidence  regarding  the  virulence  of  the 
gonococcus  appeared  as  the  result  of  the  work  of  Ferarri,^  Bouchard, 
De  Pezzer,''  de  Sinety  and  Henneguy.®  In  1886  a  number  of  observa- 
tions appeared  showing  that  a  purulent  urethritis  might  occur  as  the 
result  of  micrococci  other  than  -the  gonococci.  Thus,  Bochart^  re- 
ports that  in  four  years  he  has  seen  15  such  cases,  basing  his  conclu- 
sions upon  cultures  and  inoculations.  Similar  conclusions  were  ad- 
duced by  Peterson,*  Podres,'-'  and  C'revelli.'" 

During  the  next  year  Zeissl''  found  a  micrococcus  resembling  the 
gonococcus  in  the  discharge  from  cases  of  non-gonorrhcal  suppurating 
urethritis.  Abelaender,  Wendt,  Giovannini,'-  Lustgarten  and  Man- 
naberg"  report  finding  a  diplococcus  in  the  normal  urethra.  These 
organisms  were  both  intracellular  and  extracellular.  All  doubt  as  to 
the  virulence  and  specificity  of  the  gonococcus  was  finally  set  at  rest 

f  "seri,  J.:  Wicn.  med.  VVoch.,  1885,  No.  22  and  23. 

rrankel:  Dout.  mc.l.  Wofh.,  1SS.5,  No.  2. 
'  .Martineau:   .Ann.  Med.  C'hir.  Franc,  et  etrang.,  ISS."),  vol.  i,  p.  n;   also  La  rliniq.  sur 
la  Hlciinor.  choz  la  Fciiinif,  188.5. 

'  Korarri:   Gior.  ili  Med.,  1885,  vol.  xxxiii,  p.  .337. 

'  Dp  Pezzer:  Annal.  des  Mai.  d.  Org.  Gen.-Urin.,  188.5,  vol.  iii,  p.  9.5. 

'  de  Sinety  and  Ilenneguy :  Mfim.  de  la  .soc.  de  Biol.,  August  8,  188.5,  p.  .5.53. 

Boehart:  Monats.  f.  prakt.  Dcrmat.,  188(5,  vol.  v,  p.  134. 

I'etcrson:  St.  Pctorsl)urn  Dcul.  rued.  Zeit.,  188.5,  vol.  vi,  p.  .517. 

'  I'odre.s:  Vierteljalirossohr.  f.  Dcrmat.,  Vienna,  188.5,  p.  .5.57. 

'°  Oevelli:  Th6se  do  Pari.s,  188(i;  al.so  Australian  Med.  .lour.,  1888,  p.  89. 

"  Zeis.sl,  von:  Comp.  d.  Path.  u.  Therap.  d.  prim.  .Svph.  u.  einf.  vener.  Krank.,  \'icnna, 
18.50.  I         1  .1 

"  Giovannini:  Gaz.  dcgli  Ospcd.,  Milan,  188(i,  .No.  01. 

"  I.uslgarlcn  ami  Mann:it)erg:  ViertcljahrcssiOir.  f.  Dermal.  M.  Sypli.,  1S,S7,  p.  90.5. 


42  GONORRHEA    IN   WOMEN 

by  the  appearance  of  Bumm's^  masterly  paper,  in  which  he  adduced 
abundant  material  and  incontrovertible  proof  of  the  verity  of  his 
conclusions.  In  a  paper  published  in  1888  Schnurmans-Stekhoven^ 
questions  Bumm's  results,  and  expresses  doubt  as  to  the  existence  of  a 
specific  micrococcus  of  gonorrhea.  He  bases  his  attack  on  the  ground 
that  Bumm  had  not  proved  that  the  cultures  used  by  him  were  pure. 
Papers  tending  to  prove  that  a  urethritis  might  be  produced  by  a 
number  of  micrococci  other  than  the  gonococcus  were  pubUshed  by 
Rauzier,^  Pouey,"*  and  Legrain-^  during  1888. 

In  the  following  year  Steinschneider  and  Galewsky'^  isolated  from 
four  normal  urethras  a  diplococcus  morphologically  analogous  to  the 
gonococcus. 

Rovsing^  (1890)  reported  finding  the  Diplococcus  urese  non-pyo- 
genes  in  the  discharge  from  the  normal  female  urethra.  As  might 
have  been  suspected,  the  fincUng,  by  so  many  trustworthy  investiga- 
tors, of  diplococci  morphologically  similar  to  the  gonococcus  in  dis- 
charges from  undoubtedly  normal  urethras  created  much  confusion. 
Fortunately,  in  the  next  year  (1891)  Wertheim's  method  of  preparing 
cultures  of  the  gonococcus  permitted  so  many  positive  inoculations  to 
be  made  as  to  close  forever  the  discussion  as  to  the  pathogenic  character 
of  the  gonococcus. 

No  historic  sketch  on  gonorrhea,  however  brief,  would  be  complete 
without  a  reference  to  the  wonderful  skill  and  genius  of  Lawson  Tait, 
who  performed  much  of  the  pioneer  work  in  the  surgery  of  pelvic 
inflammatory  disease.  He  recognized  the  tubal  origin  of  these  cases, 
and  the  results  of  the  "Tait  operation,"  as  salpingo-oophorectomy 
for  adnexitis  was  called,  were  so  brilliant  as  to  attract  general  attention 
throughout  the  entire  surgical  world. 

ADDITIONAL  BIBLIOGRAPHY 

Aegineta:  The  Sydenham  Society,  London,  1S44,  P-  594. 
Andri:  De  la  Gener.  d.  vers,  dans  le  corps  d  I'homme,  Paris,  1700. 
Bokai:  Allgemeine  Med.  Central-Zeitunp.  1880,  No.  74. 
Bostock  and  Riley:  Natural  History  of  Pliny,  1856. 
Bumm:  Arch.  f.  Gyn.,  1884,  vol.  xxiii,  p.  327. 

'Bumm:  Beitriige  z.  Kennt.  d.  Gonococcus,  Wiesbaden,  1885;  also  Der  Mikro- 
organismus  d.  gonorrhoischen  Schleimhaut-Erkrankungen,  Gonococcus  Neisser,  second 
edition,  Wiesbaden,  J.  F.  Bergmann,  1887. 

2  Sehnurmans-Stekhoven:  Deut.  med.  Woch.,  1888,  No.  35,  p.  717. 

'  Rauzier:  Gaz.  Hebd.  d.  Soc.  Med.  d.  Montpellier,  February,  1888. 

*  Pouey:  These  de  Paris,  1888,  No.  262. 

'Legrain:  These  de  Nancv,  1889;  also  Annal.  des  Mai.  d.  Org.  Gen.-Urin.,  1888,  p. 
523,  etc. 

'Steinschneider  and  Galewsky:  Verb.  d.  Deut.  Dermat.  Gesell.,  Vienna,  1889,  vol.  i, 
p.  159. 

'  Rovsing:  Die  Blasenentziindung,  etc.,  Berlin,  1890. 


HISTORIC  43 

Castex:  Jour.  d.  Connais.  Med.,  1SS7,  vol.  cxl\'iii,  p.  183. 

Cockburn:  The  Symptoms,  Nature,  Cause,  and  Cure  of  Gonorrhea,  London,  1715. 

De  Amicis:  Riv.  Chn.  e  Therap.,  March  11,  1884. 

Finger,  E.:  Blennor.  d.  Sexual-Organs,  1905,  p.  14;  Blennorrhea  of  the  Sexual  Organs,  etc., 

in  Wood's  Med.  and  Surg.  Monograplis,  vol.  ii,  p.  33. 
Findley,  P. :  Gonorrhea  in  Women,  St.  Louis,  190S. 
Galen:  De  Loc.  ASec.,  2,  8,  edit.  Ruhn,  vol.  iii,  p.  91. 
Haeser:  Lehrbuch,  vol.  i,  p.  751. 
Herodotus:  History,  vol.  i,  p.  105. 
Holmes:  System  of  Surgery. 

Jou.sseaume:  Des  Veget.  Para.sit.  d.  I'homme,  Paris,  1862,  p.  130. 
Judd;   On  Venereal  and  Urethral  Diseases,  London,  1836,  p.  2. 
I\joner:  Arch.  f.  Gyn.,  1884,  vol.  xxv. 
Marcellus:  De  Med.  Empir.  Phjsic,  Basel,  1536,  fol. 
McKay:  Ancient  Gynecology,  London,  1901. 
Morrow:  N.  Y.  Med.  Jour.,  1881,  vol.  x.xxiv,  p.  271. 
Neisser:  Wiesbaden,  1887;   Trans,  of  the  Cong,  of  Ger.  Naturalists  and  Phys.  at  Strass- 

burg,  1885;  abstract  in  Centralbl.  f.  d.  med.  Wissenschaften,  1886,  No.  32. 
Preuss:  BibUsch-Talmudisehe  Medizin,  1911,  p.  409. 
Salter:   Hirschberg  u.  Lebert,  Sitzungsber.  ti.  d.  dreizehn.  Versanim.  d.  ophthal.  Gesell., 

Heidelberg,  1881,  p.  18. 
Sanger:  Verhandlung.  der  deutschen  Gesellschaft  ftir  Gynakologie,  Leipzig,  1886. 
Spooner,  H.  G. :  Amer.  Jour.  Dermatology,  1909,  vol.  xiii,  No.  4,  p.  195;   Post-Graduate, 

1905,  p.  950. 
Tait,  Lawson:   Diseases  of  Women,  London  and  Edinbtu-gh,  1877. 
Wei.ss,  F.:  Th^se  d.  Nancy.  1880;  pub.  in  Annales  de  Dermat.,  1881. 

Widmark:  Hvgiea,  September,  1884;  also  Monats.  f.  prakt.  Dermat.,  1885,  vol.  xiv,  p.  64. 
Wise,  T.  A.:  Hindu  Syst.  of  Med.,  London,  1860. 


CHAPTER  II 
BACTERIOLOGY  OF  THE  GONOCOCCUS 

The  gonococcus,  discovered  by  Neisser  in  1879,  is  the  specific 
cause  of  gonorrhea.  So  conclusively  has  this  been  proved,  that  where- 
ever  this  micrococcus  is  found,  a  positive  diagnosis  can  be  made.  In 
the  chronic,  or  so-called  latent,  cases,  especially  in  the  female,  it  is 
sometimes  extremely  difficult  to  demonstrate  the  gonococcus,  and  for 
this  reason  negative  bacteriologic  results,  unless  frequently  repeated 
and  performed  under  favorable  circumstances,  cannot  positively  ex- 
clude the  gonorrheal  nature  of  the  disease. 

It  has  been  shown  that  the  gonococcus  is  not  a  single  organism,  but 
a  group  of  organisms.  This  accounts  for  the  fact  that  autogenous 
vaccines  have  proved  most  successful,  and  that  polyvalent  serum  is 
superior  to  that  prepared  from  a  single  strain  of  gonococci.  This  fact 
also  explains,  to  a  certain  extent,  the  difference  in  severity  that  occurs 
in  different  cases  of  gonorrhea.  In  another  place  references  have  been 
quoted  that  tend  to  show  that  certain  strains  of  gonococci  are  more 
prone  than  are  others  to  produce  septicemic  or  metastatic  manifesta- 
tions of  the  disease. 

Morphology. — The  gonococcus  is  a  coffee-bean-shaped  organism; 
it  occiu's  most  frequently  in  pairs,  sometimes  in  tetrads,  and  more 
rarely  in  groups  of  8.  The  flat,  or  sometimes  slightly  concave,  sides 
of  the  organism  are  approximated,  a  narrow  space  being  visible  be- 
tween the  halves  of  the  cocci.  The  organism  is  frequently  spoken  of 
as  being  kidney,  D-,  or  biscuit-shaped,  the  Germans  likening  its  form 
to  that  of  their  "Semmel."  Unstained,  and  examined  with  a  low 
power,  the  gonococcus  appears  as  a  round  or  slightly  elongated  organ- 
ism, about  1.25/x  in  length  by  0.7  ^u  in  breadth,  the  double  nature  of 
which  cannot  be  distinguished. 

Owing  to  their  method  of  fission,  the  grouping  of  the  gonococci  is 
characteristic.  The  older  cocci  lengthen  out,  become  constricted  in 
the  middle,  and  finally  divide,  to  form  a  new  pair,  the  division  taking 
place  at  a  right  angle  to  the  median  fissure,  so  that  one  diplococcus 
develops  two  double  pairs.  At  first  the  young  organisms  are  spheric, 
but  as  they  grow  older,  the  inner  surfaces  become  flattened  or  slightly 
concave.     As  a  result  of  this  method  of  multiplication  the  gonococci 

44 


BACTERIOLOGY    OF    THE    GONOCOCCTS  45 

in  film  specimens  are  seen  to  occur  in  a  discrete  group  or  clump,  never 
in  a  chain.  The  number  of  cocci  in  each  group  is  usually  divisible  by  4. 
Perhaps  20  or  more  gonococci  may  be  observed  somewhat  closely 
packed  together,  whereas  the  remainder  of  the  field  will  be  entirely 
free  from  these  microorganisms.  Near  the  center  of  the  group  the 
cocci  are  usually  more  closely  aggregated  than  toward  the  periphery. 
This  grouping  is  similar  to  the  pattern  made  by  a  closely  choked  shot- 
gun. The  gonococci  are  found  both  intracellularly  and  extracellu- 
larh',  but  are  never  seen  within  the  nucleus.  The  intracellular  location 
is  the  more  characteristic.  This  intracellular  qualitj'  of  the  gonococcus 
doubtless,  to  a  certain  extent,  accounts  for  the  peculiar  chronicity  of 
the  disease,  as  intracellular  microorganisms  are  necessarily  less  sus- 
ceptible to  the  action  of  germicides  than  are  those  that  lie  free  in  the 
secretion. 

Dimensions  of  the  Gonococci. — The  diameter  of  the  associated 
pair  of  cocci  varies,  with  the  stage  of  their  development,  from  0.8  fi  to 
1.6  M  in  the  long  d'ameter,  by  0.6  m  to  0.8  ix  in  the  short  diameter,  the 
average  being  about  1.25  m  in  the  long  diameter  by  0.7  n  in  the  short. 
There  are  undoubtedly  many  strains  of  gono- 
cocci, and  these  vary  somewhat  in  size,  just  a*  j*  tl  fiS  **  S 
as  individuals  of  the  .same  strain  do  in  dif-  •  99  mm  mm  ««  «« 
ferent  generations,  when  grown  upon  artificial 

1-  Fig.   I. — Method  of  Rkduplica- 

meClia.  tion-  of  the  Goxococti. 

Motility. — The  gonococcus  is  generally  be- 
lieved to  bo  non-motile,  although  J.  Eisenberg  credits   tlio  organism 
with  a  rotary  or  oscillatory  movement.     It  is  certain,  howevcn-,  that 
the  gonococcus  is  not  autolocomotive. 

The  Relation  of  the  Number  and  Morphology  of  the  Gonococci  to 
the  Stage  and  Virulence  of  the  Disease.  -The  first  discharge,  th(>  result 
of  a  gonorrheal  infection,  is  made  up  of  mucus,  epithelial  cells,  red 
blood-corpuscles,  and  debris.  In  this  the  gonococci  are  found  in  vary- 
ing numbers,  fre(4uenlly  (|iiilc  ;il)undantly.  The  majority  of  organ- 
isms are  free  in  the  serum,  but  they  may  be  agglutinated  ui)on  or 
found  within  the  epithelial  cells.  P'or  diagnostic  purposes  it  is  im- 
portant to  demonstrate  the  intracellular  micnxirganisins.  This  is 
sometimes  (luite  difficult,  as  at  tiiis  stage  intracellular  gonococci  are 
comparatively  rare.  When  a  group  of  diplococci  are  found  on  a  cell, 
individual  organisms  may,  as  a  rule,  be  seen  overlapping  the  cell 
edges,  whereas  when  the  gonococci  are  actually  within  the  cell,  this 
la  not  the  ca.se.  The  difTerent  planes  that  can  be  demonstrated  iiy 
focusing  will  also  usually  dear  up  this  point.  At  this  stage  the  gono- 
cocci arc  nearly  all  of  the  well-known  cofTee-i)can  shape.     As  llic  (iise!is(> 


46  GONORRHEA    IN    WOMEN 

develops  and  the  discharge  becomes  mucopurulent,  the  number  of 
gonococci  increases  quite  markedly,  and  the  proportion  of  intracellular 
cocci  becomes  much  greater.  During  the  height  of  the  inflammation 
all  the  cellular  constituents  of  the  discharge  diminish  in  proportion  to 
the  pus-cells,  which  now  dominate  the  field.  On  account  of  the  great 
number  of  pus-corpuscles,  the  number  of  the  gonococci  appears  to  be 
diminished.  This,  however,  is  not  the  case.  At  this  stage  nearly  all 
the  gonococci  are  intracellular — indeed,  some  authorities  maintain 
that  all  the  extracellular  gonococci  that  are  found  are  the  result  of 
trauma  in  preparing  the  film,  and  are  caused  bj^  the  freeing  of  the  origi- 
nal intracellular  organism  during  attempts  to  make  a  very  thin  film  of 
the  preparation.  That  this  is  not  the  case  we  have  demonstrated  a 
number  of  times  in  films  that  have  been  prepared  without  inflicting 
any  trauma  whatever.  Large  numbers  of  gonococci  are  sometimes 
found  within  a  single  epithelial  cell  or  pus-corpuscle.  As  many  as  one 
hundred  have  been  counted,  and  although  these  cells  sometimes  appear 
as  if  ready  to  burst,  as  a  general  rule  they  present  remarkably  little 
evidence  of  injury.  Discussion  is  still  rife  as  to  whether  the  gonococci 
actually  invade  the  pus-cell  or  are  taken  up  by  them  as  the  result  of 
phagocytic  action.  The  former  seems  the  more  probable  theory,  as 
there  is  no  evidence  to  prove  that  the  gonococci  are  destroyed  by  the 
pus-corpuscle,  whereas,  on  the  contrary,  it  is  easy  to  demonstrate  that 
they  multiply  readily  within  the  cell.  Moreover,  the  fact  that  they 
are  found  within  epithelial  cells  that  have  no  phagocytic  action  what- 
ever strengthens  .this  view.  According  to  Bumm,'  the  invasion  of  the 
epithelial  cells  and  leukocytes  is  due  to  a  vital  activity  on  the  part  of 
the  microorganisms.  Large  numbers  are  sometimes  present.  Scholtz,- 
Pollock  and  Harrison,^  and  others  believe  that  intracellular  gonococci 
are  the  result  of  phagocytosis,  and  that  this  process  occurs  in  the  free 
secretion  and  not  in  the  depths  of  the  tissue,  and  state  that  if  the 
surface  discharge  be  wiped  off  and  exudate  expressed  from  the  depths 
of  the  tissue,  extracellular  organisms  are  chiefly  found. 

During  the  terminal  stage  the  number  of  gonococci  and  pus-cells  is 
diminished.  Guiteras^  states  that  at  this  time  the  pus-cells  frequently 
contain  fat-granules  and  show  other  signs  of  disiritegration.  As  a 
rule,  in  chronic  cases,  when  pus-cells  are  numerous  in  the  discharge, 
gonococci  can  be  demonstrated  without  difficulty,  but  when  pus-cells 

'  Bumm,  E.:  Der  Mikro-organismus  gonorrhuischen  Schlcimhaut-Erkrankungen, 
Wiesbaden,  1885. 

^Scholtz:  Arch.  f.  Dermat.,  1899. 

'  Pollock,  C.  E.,  and  Harrison,  L.  W.:  Gonococcal  Infections,  London,  1912,  p.  63. 

'  Guiteras,  R. :  Urology,  D.  Appleton  &  Co.,  New  York  and  London,  1912,  vol.  ii, 
p.  3.58. 


BACTERIOLOGY    OF    THE    GONOCOCCXJS  47 

are  scanty,  the  gonococci  are  few  in  number.  Large  numbers  of 
coarse-grained  eosinophile  cells  are  generally  present  about  the  third 
or  fourth  week  of  the  discharge.  During  the  chronic  stage  pus-cells 
diminish  in  number,  epithelial  elements  become  more  numerous,  and 
the  gonococci  are  lessened  in  number.  In  the  secretion  from  the  ure- 
thra at  this  stage  the  so-called  "clap  shreds"  are  present.  These  con- 
sist mainly  of  transient  epithelium,  mononuclear  leukocytes,  a  few 
gonococci,  and  pus-corpuscles.  With  the  diminution  in  the  amount  of 
pus  a  relatively  greater  number  of  extracellular  gonococci  are  found. 
During  the  chronic  or  terminal  period  involution  forms  of  gonococci 
are  sometimes  encountered.  These  are  often  granular  in  appearance, 
round  or  irregular  in  shape,  and  have  varjdng  staining  properties. 
Wynn'  states  that  the  more  active  the  lesion,  the  greater  are  the 
nimiber  of  extracellular  gonococci  present. 

Thus  we  see  that  the  microscope  furnishes  a  very  important  means 
not  only  of  diagnosing  gonorrhea,  but  of  differentiating  between  the 
various  stages  of  the  disease.  Harmsen-  and  Sireday  and  Bigart' 
have  demonstrated  the  value  of  the  microscope  in  this  connection. 

It  has  been  asserted  that  the  number  of  gonococci  in  the  secretion 
in  a  given  Case,  the  previous  historj^  of  which  is  known,  may  be  taken 
as  a  guide  as  to  the  probable  course  and  virulence  of  the  infection. 
This  theory  is  doubtful,  for  the  gonococci  are  at  no  time  equally  dis- 
tributed throughout  the  discharge,  and  to  be  of  any  value  whatever,  a 
large  number  of  preparations  must  be  examined.  The  prolonged  con- 
tinuance of  large  amounts  of  pus-  and  of  numerous  gonococci  in  the 
secretion  is,  however,  certainly  an  evidence  of  the  chronicity  of  the 
period  of  active  inflammation.  However,  clinical  manifestations  are 
usually  sufficient,  at  this  time,  to  demonstrate  such  a  condition. 

During  the  stage  of  active  inflammation  there  is  usually  no  difficulty 
in  demonstrating  the  gonococci  in  smear  preparations,  provided  these 
are  properly  i)repared.  Later,  however,  during  the  chronic  period, 
this  is,  unfortunately,  far  from  being  the  case.  At  this  time  gonococci 
are  often  found  only  after  a  most  thorough  search.  This  is  true  in  the 
male,  but  is  more  especially  noticeable  in  the  female.  A  knowledge 
of  how,  when,  and  from  where  to  obtain  the  secretion  to  be  examined 
during  this  stage  of  the  disease  is  of  great  aid  in  clearing  up  a  doubtful 
diagnosis.  In  the  female,  film  preparations  should  be  made  from  the 
discharge  obtained  from  the  cervix,  urethra,  vulvovaginal  glands,  and 
the  vagina,  althougli  that  from  the  latter  is  of  little  value  compared  to 

'  Wyiiri;   Liiiiccl,  I'.ll).'),  vol.  i,  No.  (i,  p.  :i.5J. 

'  Hiirmscn:  Zcit.  f.  Hy(;.  u.  Infektions-Krankh.,  1900,  vol.  liii,  p.  89. 

^  Sireday  ami  Bigarl:  .\iiiial.  do  (Jyii.  et  d'Olwt.,  Docembor,  1905. 


48  GONORRHEA    IN    WOMEN 

that  obtained  from  the  other  structures  named.  The  times  when  gono- 
cocci  are  most  likely  to  be  found  are  immediately  after  the  menstrual 
periods  and  during  the  first  few  days  following  labor,  miscarriage,  or 
abortion,  when  the  lochia  is  beginning  to  diminish.  It  should  be 
remembered  that  excesses  of  all  kinds,  paid  at  the  shrine  either  of 
Venus  or  of  Bacchus,  are  likely  temporarily  to  light  up  a  chronic  or 
latent  gonorrhea,  and  as  a  consequence  gonococci  will  more  readily 
be  found  immediately  following  such  periods.  Wlien  examining  pa- 
tients during  periods  when  gonococci  are  not  likely  to  be  numerous, 
the  passage  of  a  catheter  a  short  distance  into  the  urethra  or  a  slight 
dilatation  of  the  lower  cervical  canal  will  set  up  a  mild  traumatic  irri- 
tation in  the  discharge,  from  which  the  organism  can  often  be  easily 
demonstrated,  or  the  suspected  area  may  be  touched  with  a  solid 
stick  of  silver  nitrate,  and  in  the  exudate  from  the  irritation  thus  pro- 
duced the  organism  may  be  found.  If  cultures  are  to  be  taken,  care 
must  be  observed  that  all  the  silver  has  disappeared;  this  is  usually 
the  case  at  the  expiration  of  twenty-four  hours.  The  alcohol  test  is  a 
favorite  one  with  many  genito-urinary  specialists,  and  consists  in 
having  the  patient  drink  a  few  glasses  of  beer,  champagne,  or  Burgundy 
for  a  few  days  prior  to  the  examination,  and  a  few  pickles  added  to  the 
diet  are  recommended  by  some  authorities.  In  the  mean  time  all 
treatment  is  suspended.  Similar  means  may  be  employed  as  a  test 
for  cure,  and  should  be  repeated  with  negative  results  at  least  three 
times  before  a  clean  bill  of  health  is  given. 

The  "beer  test"  is  of  less  value  in  the  female  than  in  the  male,  as 
its  efficacy  depends  largely  upon  producing  an  irritating  urine.  As 
urethritis  in  women  is  usually  of  secondary  importance  to  the  cervical 
infection,  the  benefit  to  be  derived  from  this  test  under  such  circum- 
stances is  somewhat  iiinited.  Van  de  Velde'  and  others  state  that  a 
diagnostic  vaccination  often  produces  an  increased  secretion  in  which 
gonococci  are  more  numerous,  and  are  often  thus  easily  found  when 
they  could  not  previously  be  demonstrated.  When  obtaining  the 
secretion  from  the  urethra,  the  material  should  be  expressed  by  firm 
milking  movements,  as  in  this  way  the  discharge  is  obtained  from  the 
deeper  crypts  and  glands,  and  contamination  from  other  bacteria 
usually  present  about  the  meatus  is  avoided;  besides,  the  secretion  is 
secured  from  the  most  recent  and  freshly  inflamed  parts.  This  dis- 
charge will  be  found  to  contain  more  gonococci  than  that  secured  from 
the  surface,  from  which  point  the  inflammation  has  probably  passed 
its  acme  at  the  time  of  examination.  For  the  same  reasons,  in  making 
films  from  the  cervical  secretion,  the  material  should  be  obtained  from 

1  Van  de  Velde:  Monats.  f.  Geb.  u.  Gyn.,  April,  1912. 


BACTERIOLOGY    OF    THE    GONOCOCCUS  49 

a  point  well  within  the  cervical  canal,  after  having  first  compressed 
this  organ.  Frequently  a  slight  irritation,  either  chemical  or  trau- 
matic, will  be  sufficient  to  set  up  a  mild  local  irritation,  in  the  discharge 
from  which  gonococci  can  readily  be  demonstrated  after  a  failure  to 
demonstrate  them  by  ordinary  means.  In  such  an  event  the  secre- 
tion for  examination  should  not  be  taken  until  twenty-four  hours 
afterward,  and  this  is  particularly  true  if  the  irritation  has  been  pro- 
duced bj^  an  antiseptic,  such  as  a  strong  solution  of  silver,  which  is 
often  used  for  this  purpose.  Gonococci  are  usually  absent,  or  present 
only  in  diminished  numbers,  immediately  after  treatment  by  anti- 
septics. ^^'henever  practicable,  it  is  best  to  secure  the  suspected 
secretion  early  in  the  morning.  At  this  time  the  urethral  canal  has 
probably  not  been  washed  out  so  recently  by  the  passage  of  urine,  and, 
besides,  as  Finger  has  pointed  out,  more  excretion  is  formed  at  night. 
This  is  not  so  true  of  patients  who  are  bedfast.  In  chronic  or  latent 
cases  it  should  alwaj's  be  borne  in  mind  that  the  gonococci  are  present 
only  in  small  numbers,  and  that  the  amount  of  secretion  examined  on  a 
given  slide  is  comparatively  infinitesimal;  for  this  reason  a  number  of 
preparations — at  least  three  or  four — should  be  made  from  the  secre- 
tion of  each  suspected  locality,  and  such  examinations,  if  negative, 
should  be  repeated  on  two  or  three  successive  days.  A  movable  stage 
is  a  great  aid  in  examining  such  preparations,  for  by  its  use  the  entire 
slide  may  be  inspected  s^'stematically.  In  those  chronic  cases  in  which 
it  is  impossible  to  demonstrate  the  gonococci  by  staining  methods,  and 
in  which  the  clinical  manifestations  point  toward  a  Neisserian  infec- 
tion, or  when  the  medicolegal  aspect  of  the  case  is  involved,  cultures 
should  be  made.  These,  because  of  the  difficulty  attending  the 
growth  of  the  gonococci  on  artificial  media,  are  of  value  only  when 
performed  by  a  skilled  bacteriologist. 

Staining  Properties  of  the  Gonococcus. — The  gonococci  stain 
readily  with  any  of  the  anilin  dyes.  In  order  satisfactorily  to  demon- 
strate the  organism,  the  point  to  be  desired  is  to  stain  the  gonococci 
somewhat  deeply  and  the  surrounding  structures  as  little  as  possible, 
so  that  the  bacteria  will  stand  out  prominently.  For  this  reason, 
whatever  stain  is  selected,  care  should  be  taken  not  to  overstain  the 
preparation.  For  staining  film  preparations,  a  great  number  of 
methods  are  in  use.  Any  of  the  basic  anilin  dj^es,  if  projierly  diluted, 
will  give  good  results.  For  demonstrating  the  presence  of  gonococci 
in  pus,  I.oflicr's'  solution  of  methjdene-blue  is  one  of  the  best,  for  while 
staining  the  gonococci  deeply,  it  leaves  the  cell  cytoplasm  but  faintly 
colored.     Methyl-violet,    gentian-violet,    Bismarck-brown,    safranin, 

'  LofUtT  ami  Lcistikiiw:  C'h:iiit('-Aiiiuil('ii,  Jahrgang  7. 
i 


50  GONORRHEA    IN   WOMEN 

malachite-green,  or  fuchsin  may  also  be  employed.  These  last  are 
perhaps  superior  to  methylene-blue  when  the  suspected  material  is 
free  from  or  contains  but  little  pus.  The  specimen  may  be  either  air 
dried  and  fixed  by  being  passed  through  the  flame,  or  may  be  air  dried 
and  then  fixed  by  placing  the  films  in  a  solution  of  equal  parts  of  abso- 
lute alcohol  and  ether  for  fifteen  minutes.  The  former  method  is  the 
quickest ;  the  latter  gives  more  beautiful  preparations.  The  following 
is  an  excellent  simple  stain  when  pus  is  present  in  the  discharge: 

Loffler's  Methylene-blue  Solution  for  Staining  Gonococci 
(a)  Spread  pus  evenly  over  the  cover-glass. 
(6)  Air  dry. 

(c)  Fix  either  by  passing  through  flame  three  times  or  by  placing  in  equal 
parts  of  ether  and  absolute  alcohol  for  fifteen  minutes. 

(d)  Cover  smear  with  a  solution  of  methylene-blue  (saturated  95  per 
cent,  alcoholic  solution  of  methylene-blue,  30  c.c;  to  a  solution  of  potassium 
hydroxid  in  water,  1:10,000,  100  c.c.)  for  two  minutes. 

(e)  Wash  in  tap-water. 

(/)  Dry  with  buff  photo  blotting-paper. 
{g)  Mount  in  xylol  balsam. 

Result:  Gonococci  stain  deep  blue;  nuclei,  a  lighter  blue;  and  proto- 
plasm, pale  blue. 

If  speed  is  desired,  the  method  advocated  by  Bumm  may  be 
adopted.  This  consists  of  substituting  for  the  methylene-blue  a 
concentrated  watery  solution  of  fuchsin,  this  stain  requiring  only 
thirty  seconds.  The  preparation  may  be  examined  without  a  cover- 
glass.  A  2  per  cent,  alcoholic  solution  of  methyl-violet  solution  may 
also  be  employed.  This  is  practically  a  differential  stain,  and  may  be 
used  very  rapidly.  It  gives  excellent  results.  Some  authorities 
prefer  to  examine  the  suspected  secretion  by  drying  it  on  the  slide 
without  fixing.  It  is  then  stained  and  examined  while  still  damp.  It 
is  claimed  for  this  method  that  by  it  the  gonococci  are  larger  and  more 
readily  detected.  In  cases  in  which  difficulty  is  encountered  in  demon- 
strating the  gonococci,  or  for  class  demonstration,  one  of  the  double 
stains  is  often  of  value.     These  also  make  beautiful  preparations. 

Neisser's  method  of  double-staining  gonococci  is  as  follows: 

Neisser's  Method  of  Double  Staining  Gonococci  in  Smear  Prepara- 
tions 

(o)  Place  the  fixed  specimen  in  a  concentrated  alcohohc  solution  of 
eosin  and  heat  gently  for  three  minutes. 

(6)  Drain  off  eosin,  wash  in  tap-water,  and  place  immediately  in  a  satu- 
rated 95  per  cent,  solution  of  methyl-blue  for  forty-five  seconds. 


BACTERIOLOGY    OF   THE    GONOCOCCUS  51 

(c)  Wash  in  tap-water. 

(rf)  Dry  with  the  aid  of  buff  photo  blotting-paper. 

(e)  Mount  in  xj-lol  balsam. 

Result:   Gonococci  and  cell  nuclei  stain  blue;  protoplasm,  a  dull  red. 

F.  Abbott  recommends  the  following  double  stain: 

Abbott's  Staining  IMethod 

(a)  Spread,  dry,  and  fix  in  the  usual  manner. 

(b)  Treat  ^\ith  20  per  cent,  solution  of  tannic  acid  for  one  or  two  minutes. 

(c)  Wash  in  alcohol. 

(d)  Dry  ^ith  filter-paper. 

(e)  Stain  with  Ziehl's  solution  of  fuchsin. 

(f)  Decolorize  in  acid  alcohol  (acetic  acid,  1  part;  alcohol,  100  parts; 
or  hydrochloric  acid,  1  part;   alcohol,  500  parts). 

ig)  Dry. 

(h)  Stain  with  meth3-l-green. 

(0  Wash  in  water. 

(i)  Mount. 

Result:  Gonococci  are  dark  red;  nuclei,  purple;  protoplasm,  light  green. 

Another  double  stain  is  as  follows: 

(a)  Prepare  and  fix  films  in  the  usual  manner. 

(6)  Stain  for  thirty  seconds  in  a  freshly  made  mixture  of  Lofller's  methy- 
lene-blue  (30  c.c.  of  saturated  alcoholic  solution  of  methylene-blue  to  which 
100  c.c.  of  0.01  per  cent,  of  caustic  potash  (1  c.c.  of  1  per  cent,  caustic  potash  to 
100  c.c.  of  water)  has  been  added.  This  solution  keeps  M^ell),  30  parts, 
saturated  alcoholic  solution  of  eosin,  10  parts. 

(f)  Wash  and  mount  in  the  usual  manner. 

Result:  Bacteria  and  cell  nuclei  blue;  the  remainder,  red. 

Pappexheim's  Stain 

(a)  Prepare,  dry,  and  fix  in  the  usual  manner. 

(6)  Stain  for  four  minutes  in  methyl-green,  0.15  gram;  pyronin,  0.25 
gram;  alcohol,  2.5  c.c;  glycerin,  20  c.c;  phenol  in  water  (2  per  cent,  solution). 
100  cc 

(c)  Wash  in  water. 

((/)  Dry  with  blotting-i)aper. 

(e)  Mount  in  the  usual  manner. 

Result:   The  gonococci  arc  red  and  t!ie  cell  nuclei  are  blue. 

A  simple  ni(!thod  of  applying  I'appenhcini's  stain,  and  one  giving 
ahnost  as  reliable  results,  is  as  follows: 

(n)  Prepare,  dry,  and  fix  in  the  usual  manner. 

(/>)  Stain  for  one  minute  in  the  following  solution:   To  5  c.c.  of  distilled 


No.  2: 


52  GONORRHEA    IN    WOMEN 

water  add  methylene-green,  about  twdce  as  much  as  can  be  placed  on  the  end 
of  the  blade  of  a  pen-knife,  and  one-fourth  this  amount  of  pyronin  (Grtibler, 
Leipzig).     This  solution  should  be  of  a  blue-violet  color. 

(c)  Wash  in  water. 

(d)  Mount  in  the  usual  manner. 
Result:  Gonoeocci  are  red;  nuclei,  blue. 

One  of  the  best  of  the  counterstains  is  that  recommended  by  Sax,' 
and  known  as  the  modified  Romanowsky-  stain.  With  this  method 
the  smears  require  no  previous  fixation,  as  the  methyl-alcohol  accom- 
plishes this  while  the  staining  is  going  on.  For  this  reason  the  un- 
diluted stain  is  first  poured  on  the  slide.  Then,  in  order  to  differen- 
tiate, distilled  water  is  added  as  described  below.  Two  solutions  are 
used,  which  should  be  kept  in  separate  well-stoppered  bottles.  They 
consist  of: 

No.  1: 

Aqueous  eosin  ("W.  G."  Grtibler) 1  part 

Methyl-alcohol,  chemically  pure,  absolute.  .  .  .  100  parts 

Methylene-blue  (pure,  medicinal)  (Grtibler)  .  .      1  part 
Methyl-alcohol,  chemically  pure,  absolute.  .  .  .  100  parts 

Equal  parts  of  No.  1  and  of  No.  2  are  mixed  and  poured  on  the 
slide,  where  they  should  be  allowed  to  remain  not  longer  than  one 
minute.  Distilled  water  is  then  added  to  the  dye  until  about  four 
times  the  amount  of  the  original  fluid  is  on  the  smear.  This  remains 
on  the  slide  for  five  minutes,  and  is  then  washed  off  with  distilled  water 
and  the  slide  dried  and  examined.  The  resulting  smear  shows  the 
nuclear  material  and  bacteria  blue,  and  the  background  salmon  col- 
ored, with  dark-pink  cell-bodies.  Or  the  following  method  may  be 
employed : 

Romanowsky's  Stain  (Leishman's  Modification) 
Dissolve  one  "Soloid"  product  of  Romanowsky's  stain  (Leishman's  pow- 
der), 0.015  gram,  in  10  c.c.  of  pure  methyl-alcohol.  Allow  this  solution  to 
stand  for  about  three  or  four  hours  before  using.  Spread  j3us  evenly  over  the 
cover-glass  and  allow  same  to  dry  in  the  air.  Without  fixing  the  specimen 
drop  enough  of  the  prepared  stain  on  it  completely  to  cover  the  smear.  Allow 
the  stain  to  act  for  from  fifteen  to  thirty  seconds,  and  then  add  as  many  drops 
of  distilled  water  as  were  used  of  the  stain.     The  diluted  stain  should  remain  on 

'  Sax:  Trans.  Araer.  Urol.  Assoc,  1909,  Brookline,  1910,  vol.  iii,  p.  131. 
'Romanowsky,  D. :  St.  Petersburg,  med.  Wochenschr.,  1891,  No.  34,  p.  297. 


BACTERIOLOGY   OF   THE    GONOCOCCUS  53 

the  slide  for  from  five  to  ten  minutes,  after  which  time  it  is  washed  off  with 
tap-water  and  the  slide  dried  with  blotting-paper.  Mount  in  xj-lol  balsam. 
Result:  Cocci  stain  blue;  nuclei  of  leukocj'tes,  rose-red;  eosinophile 
granules,  red;  protoplasm  of  mononuclear  and  coarsely  grained  eosinophile 
cells,  light  blue. 

McKee'  recommends  that  the  films  be  prepared  after  the  method 
used  in  trachoma  cases.  The  material  is  spread  on  the  slide,  dried  in 
the  air,  fixed  for  ten  minutes  in  80  per  cent,  alcohol,  stained  with 
Giemsa's  solution,  1,  to  20  parts  of  distilled  water,  for  twenty  minutes. 
Or  Giemsa's  new  method  may  be  employed.  This  is  as  follows:  Dry 
the  film  in  the  air,  fix  in  80  per  cent,  alcohol  for  ten  minutes,  place 
film  in  a  Petri  chsh,  and  cover  with  staining  fluid  consisting  of  equal 
parts  of  Giemsa  stain  and  pure  methyl-alcohol.  Stain  thus  for  thirty 
seconds,  then  add  10  or  15  c.c.  of  cUstilled  water,  and  agitate  until  the 
mixture  becomes  homogeneous.  In  three  minutes  remove  and  pro- 
ceed to  mount  the  specimen  in  the  ordinary  manner.  McKee  states 
that  by  either  of  these  stains  gonococci  may  be  demonstrated  in  epi- 
thelium when  ordinary  methods  fail. 

Leszczynsky's  Stain^ 
The  smear  is  prepared  and  fixed  in  the  usual  way. 

Stain  for  one  or  two  minutes  or  until  smear  is  deep  liiuc,  in  tlio  following 
mixture: 

Saturated  watery  solution  of  thionin-bhic  10.0 

Phenol  (pure) 2.0 

Distilled  water 88.0 

Wash  in  distilled  water  and  stain  for  forty-five  seconds  to  one  minute,  or 
until  a  clear  yellow,  in: 

Saturated  watery  .solution  of  picric  acid /  ^       , 

Solution  of  potassium  hydroxid  (0.1  per  cent.) ..  1 

Wash  with  distilled  water,  dry  with  blotting-paper,  immerse  in  absolute 
alcohol  for  five  seconds,  wash  again  with  distilled  water,  dry  with  blotting- 
paper,  and  mount  in  xylol  balsam. 

Result:  Intracellular  but  not  extracellular  cocci  stain  black. 

Knaack's  MKTHon  OK  Staining  Gonococci  in  Smear  Puepakations 

(«)   Prc])are  in  ordinary  manner,  air  dry,  ami  fix. 

(h)  Stain  in  a  saturatrd  !).")  piT  cent.  a!coii(ilic  solution  of  nietli.\lcne-bhie 
for  three  miiuites. 

(c)  W'lisU  in  tap-water  and  tlry  with  buff  i)hoto  lilotting-jiapcr. 

'  M(K<c,  II.:  Tlic()|)litli:ilmir  Ucci.ni,  .January.  l!)l-_',  p.  I. 

■  I'oll(»k,  C.  i;.,  and  ll.inisdii,  I..  \V.:   Coriococcal  Iiifoclums,  I.oiid.in,  I'.MJ,  p.  •JIC. 


54  GONORRHEA    IN    WOMEN 

(d)  Place  in  a  1  per  cent,  solution  of  argonin  and  distilled  water  for  four 
minutes. 

(e)  Wash  in  distilled  water. 

(/)  Place  in  a  watery  solution  of  fuchsin  (saturated)  for  ten  seconds. 
Ig)  Wash  in  tap-water,  dry  with  blotting-paper,  and  mount  in  xylol 
balsam. 

Result:  Gonococci  stain  blue;  protoplasm,  pale  pink;  nuclei,  purple. 

Lanz's  Stain^ 
Saturated  solution  of  thionin-blue  in  2  per  cent. 

phenol 4.0  parts;  to 

Saturated  solution  of  fuchsin  in  2  per  cent,  phenol 1.0  part 

Mix  solution  immediately  before  use  and  allow  the  stain  to  act  for  from 
fifteen  to  thirty  seconds,  wash  in  distilled  water,  dry  with  blotting-paper,  and 
mount  in  xylol  balsam. 

Result:  Cocci  stain  blue;  nuclei  of  cells,  bluish  red;  and  their  proto- 
plasm, hght  red. 

Methyl-green-pyronin   Stain    (Unna-Pappenheim)    for   Gonococci   in 

Tissues 

Methyl-green  (00  crystals  (Griibler) ) 0.15  gram 

Pyronin 0-50 

96  per  cent,  alcohol 5.00  c.c. 

Glycerin  20.00    " 

Warm  the  solution  and  stain  the  sections  for  four  or  five  minutes  in  the 
incubator;    wash  in  cold  distilled  water.     Dehydrate  quickly  in  absolute 
alcohol,  clear  in  xylol,  and  mount  in  xylol  balsam. 
Result:  Gonococci  stain  red;  cell  nuclei,  blue. 

Staining  by  the  foregoing  methods,  while  it  brings  out  the  gonococci, 
also  colors  other  organisms.  Only  rarely  are  other  bacteria  morpho- 
logically similar  to  the  gonococci  present  in  the  male  urethra.  The 
same  cannot  be  said  for  the  female  genital  tract,  which,  especially  in 
the  multipara,  literally  swarms  with  organisms,  some  of  which,  stained 
by  the  methods  just  described,  are  indistinguishable  from  the  gono- 
coccus. 

It  is  to  Dr.  Gabriel  Roux,=  of  Paris,  that  we  are  indebted  for  the 
discovery  of  a  means  that  practically  difTerentiates,  by  a  rapid  stain- 
ing method,  the  gonococcus  from  all  other  morphologically  similar 
organisms  found  in  the  genital  tract.  The  method  referred  to  is  the 
staining  of  suspected  material  by  Gram's  solution.  In  1886  Roux 
published  his  conclusions.  His  findings  were  confirmed  in  the  follow- 
ing year  by  Allen'  and  Wendt,'*  of  New  York,  whose  papers,  although 

'Pollock,  C.  E.,  and  Harrison,  L.  W.:  Gonococcal  Infections,  London,  1912,  p.  216. 
2  Roux,  G.:  Le  Concours  Medical,  November  13,  1886;  also  Report  Acad,  des  Scien.j 
Paris,  November  8,  1886. 

=  Allen,  C.  W.:  Jour.  Cutan.  and  Genito-urin.  Dis.,  N.  Y.,  1837,  vol.  v,  p.  81. 
<  Wendt,  C.  E.:  Med.  News,  Phila.,  1887,  vol.  1,  p.  455. 


BACTERIOLOGY   OF    THE    GONOCOCCUS  55 

appearing  separately,  are  practicallj'  identical  in  so  far  as  results  are 
concerned. 

Gonococci  are  decolorized  by  Gram's  stain,  and  in  this  they  differ 
from  the  majority  of  other  bacteria  found  in  the  genitalia,  with  which 
they  are  likely  to  be  confused. 

In  cases  in  which  the  diagnosis  is  of  great  importance,  or  to  secure 
medicolegal  evidence,  this  method  is  not  sufficient,  and  cultures  must 
be  resorted  to.  Gram's  method  is  also  uncertain  when  "clap  shreds" 
are  present.  In  chronic  cases  gonococci  may  occasionally  stain  ir- 
regularh^  by  Gram's  method,  or  be  themselves  atjqjical  in  shape. 
Gram's  method  of  staining  is  as  follows: 

Gram's  Staining  Method 

(a)  Prepare,  dry,  and  fix  the  secretion  in  the  usual  manner. 

(b)  Stain  in  anilin-water-gentian-violet  or  anilin-water-methyl-blue  for  at 
least  two  minutes.  (This  solution  may  be  made  as  follows:  Place  sufficient 
anilin  water  in  a  test-tube  to  cover  the  bottom.  Then  fiJl  the  tube  three- 
fourths  full  with  distilled  water.  Shake  well.  After  shaking,  undissolved 
oil  should  be  present.  Filter  through  moist  filter-paper.  The  filtrate  must 
be  clear.  If  any  oil-droplets  have  passed  through,  refilter.  To  this  clear 
solution  of  anilin  oil  add  a  saturated  solution  of  gentian-violet  or  methyl- 
violet  until  a  shining  film  appears  on  the  surface,  or  as  much  dye  as  will  dis- 
solve may  be  added.  The  staining  properties  of  this  mixture  may  be  in- 
creased by  adding  1  e.c.  of  a  1  per  cent,  solution  of  sodium  hj'droxid  to  100  c.c. 
of  the  mixture.  These  stains  do  not  keep  well,  nor  does  anilin-watcr,  and 
therefore  should  be  freshly  prepared.) 

(c)  Wash  in  anilin-water. 

{d)  Stain  in  Gram's  solution  for  from  thirtj'  seconds  to  two  minutes,  ac- 
cording to  the  thickness  of  tlie  film,  etc.  (Gram's  solution  consists  of  1  part 
of  iodin;  2  parts  of  potassium  iodid,  and  300  parts  of  distilled  water.  It  is 
best  to  dissolve  the  iodin  and  potassium  iodid  in  5  parts  of  water  and  then  add 
this  to  the  remaining  29.5  i)arts  of  water.) 

(e)  Decolorize  the  preparation  in  absolute  alcoiiol  until  no  more  color  is 
given  off.  (It  is  best  to  use  two  or  three  alcohols.)  At  this  stage  Gram's 
positive  bacteria  are  stained  blue  black,  while  Gram's  negative  organisms 
are  unstained.  The  cover-glass,  therefore,  can  now  be  examined  in  water 
or  may  be  dried  and  mounted  in  balsam  or  may  be — 

(/)  CounttTstaincd  with  a  watery  snhition  of  fuchsiii,  tliiity  seconds  to 
one  minute,  and  then — 

(g)  Washed  in  water. 

{h)  Mounted  in  the  usual  mamiiT. 

(iram's  method  may  also  be  applied  as  follows:  To  10  c.c.  of  dis- 
tilled water  add  2  e.c.  of  anilin  oil.     Sliake,  and  filter-  tlirdugh  moist 


56  GONORRHEA    IN    WOMEN 

filter-paper  to  remove  oil-globules.  To  the  clear  filtrate  add  1  c.c.  of 
98  per  cent,  alcohol  and  a  like  amount  of  a  concentrated  alcoholic 
gentian-violet  solution.  After  fixing  the  suspected  secretion  by  pass- 
ing it  through  the  flame  in  the  usual  manner  it  is  covered  with  this 
solution  for  from  two  to  three  ininutes.  Drain  off  excess  of  stain  with 
filter-paper  (do  not  wash  in  alcohol) .  The  cover-glass  is  now  placed  in 
Gram's  solution  for  five  minutes,  and  thence  transferred  to  absolute 
alcohol  to  decolorize.  This  should  be  continued  until  the  drainings 
fail  to  stain  the  filter-paper.  After  the  alcohol  the  preparation  is 
washed  in  water  and  placed  in  a  solution  of  Bismarck  brown,  1  part, 
and  water,  5  parts.  In  this  it  is  allowed  to  remain  for  one  or  two  min- 
utes, or  for  forty-five  seconds  in  a  saturated  aqueous  solution  of  Bis- 
marck brown  diluted  with  three  times  its  volume  of  water.  It  is  then 
washed  in  water  and  mounted  in  the  usual  way.  The  gonococci, 
having  been  decolorized  by  the  Gram  stain,  are  now  bi'own. 

Gram's  Method  for  Sections 

(a)  Stain  with  anilin-water-gentian-violet  or  anilin-water-methyl-blue 
or  from  ten  to  twenty-five  minutes. 

(6)  Wash  in  anilin-water  thirty  seconds. 

(c)  Transfer  to  Gram's  solution  for  one  to  two  minutes.  (Sections  now 
become  brown.) 

(rf)  Wash  in  .absolute  alcohol  until  section  appears  nearly  or  entirely 
unstained.  The  purple  color  of  the  gentian-violet  changes  to  dirty  yellowish 
brown,  and  the  section  resembles  tea-leaves.  Section  must  become  brown. 
In  the  alcohol  the  purple  color  of  the  gentian-violet  returns  and  is  dissolved 
out,  so  that  if  the  manipulations  have  been  properly  performed,  the  films  at 
this  stage  are  practically  colorless.  The  decoloration  may  be  hastened  by 
moving  the  section  gently  about  in  the  alcohol.  Two  or  three  baths  are 
usually  required — a  fresh  one  as  soon  as  the  first  becomes  discolored.  If 
drop  glasses  are  used  for  decolorizing,  it  is  important  to  remember  the  side  of 
the  slide  on  which  the  section  is,  for  this  is  somewhat  difficult  to  determine 
after  decolorization  has  taken  place.  At  this  stage  the  section  may  be  cleared 
in  cedar  oil  and  mounted;  Gram's  positive  organisms  are  blue  black,  and 
Gram's  negative  bacteria  are  unstained,  or  the  section  may  be  counterstained 
to  bring  out  the  tissue  and  micrococci  that  are  not  stained  by  Gram's  solution. 

(e)  For  countcrstaining,  wash  in  water  and  immerse  in  a  solution  of 
dilute  fuchsin  for  from  five  to  ten  minutes.  If  desired,  a  solution  of  eosin  may 
be  substituted  for  the  fuchsin  for  fifteen  or  thirty  seconds. 

(/)  Wash  in  60  per  cent  alcohol. 

(g)  Dehydrate  in  absolute  alcohol. 

{h)  Clear  in  cedar  oil  or  xylol  and  mount. 

Result:  All  the  Gram-positive  bacteria  are  stained  blue  black;  the  tissue, 
red;  the  cell  nuclei,  pale  blue  or  even  dark  blue.     Bacteria  are  frequently  not 


BACTERIOLOGY    OF    THE    GONOCOCCUS  57 

stained  equally  well  in  all  parts  of  the  section,  and  this  is  particularly  likely 
to  be  so  if  the  section  is  a  large  one  or  thicker  than  5  ix. 

Gram's  method,  modified  as  follows,  has  the  advantage  that  the 
stain  in  the  preparation  keeps  much  better.  Instead  of  making  up  the 
stain  with  anilin-water,  a  0.5  per  cent,  solution  of  carbol-water  is  sub- 
stituted. After  staining,  the  preparation  should  be  washed  in  carbol- 
water  of  a  corresponding  strength.  The  addition  of  one-tenth  part 
of  a  solution  of  methylene-blue  is  recommended  for  decolorizing. 
For  decolorizing  quickly  Gunther  prefers  absolute  alcohol  to  which  is 
added  sufficient  hydrochloric  acid  to  make  the  entire  solution  3  per 
cent.  This  is  followed  by  absolute  alcohol  alone.  Nicolle  recom- 
mends carbol-water  gentian- violet,  made  with  1  per  cent,  carbol- 
water  and  iodid  solution  as  follows:  One  part  of  the  iodid,  2  parts  of 
potassium  iodid,  plus  200  parts  of  water.  For  decolorizing,  he  em- 
ploys an  alcoholic  solution  of  acetone. 

AATien  decolorizing,  after  using  Gram's  stain  special  care  must  be 
taken,  for  if  left  in  alcohol  too  long,  even  the  Gram-positive  micrococci 
will  be  decolorized,  whereas  if  the  preparation  be  left  in  loo  short  a 
time,  Gram's  negative  bacteria  will  retain  some  of  the  stain.  For  this 
reason,  when  possible,  it  is  advisable  to  place  on  one  corner  of  the 
cover-gla.ss  holding  the  material  about  to  be  examined  a  small  quantity 
of  a  culture  from  some  known  Gram-positive  organism,  and  on  an- 
other corner  a  few  anthrax  or  other  Gram-negative  micrococci.  In 
this  way  control  strains  may  be  easily  and  certainly  obtained.  It  is 
also  an  excellent  plan  to  have  at  hand  some  gonococci  of  undoubted 
authenticity,  to  compare  with  doubtful  specimens.  These  slides 
should  be  stained  in  the  same  manner  as  the  slides  containing  the 
material  for  diagnosis.  Weinrich'  rejects  practically  all  modifica- 
tions of  Gram's  stain,  and  warns  especially  against  the  use  of  acetone- 
alcohol  (Nicolle's  method),  and  still  more  against  the  use  of  acid  alco- 
hol for  decolorizing  gonococci,  these  methods  having  a  tendency  to 
decolorize  (iram-positive  diplococci.  Van  Derbergh-  and  Pultrock' 
recommend  absolute  alcohol  for  decolf)rizing,  but  apply  it  for  not  more 
than  thirty  seconds,  and  never  "until  no  more  violet  comes  off." 

Koyes'  stains  the  films  for  three  minutes  in  a  solution  consisting  of 
aniiiii  oil,  ,'5  parts;  absolute  alcohol.  7  parts:  distilled  water,  90  parts; 
these  arc  shaken  well  together  and  filtered  through  moist  lilter-i)aper 

'  Wciiiricli,  M.iCf-nt.  f.  Hakt.,  etc.,  Aht.,  Joim,  1H98,  vol.  xxiv,  |>i).  2.>S-26.">;  also  Ann. 
d.  nial.  <1.  orj;.  gcnito-uriii.,  Paris,  189S,  vol.  xvi,  p.  504. 
'Van  DiTborgh:    Cr-nl.  f.  Bakt.,  vol.  xx. 
'  Paltrock:  Der  Cionokokkus  N('i.s,scii,  Doi-|iat,  1SI07,  p.  OS. 
'  Kpycs,  E.  L.:  Di.soa.se.s  of  the  Genito-urinary  Organs,  Hill,  pp.  98-100. 


58  GONORRHEA    IN    WOMEN 

until  the  filtrate  is  clear;  it  is  then  stored  for  twenty-four  hours  and 
the  supernatant  fluid  is  pipeted  off  as  required.  After  staining  a 
number  of  slides  in  this  solution  one  is  washed  off  in  water  and  exam- 
ined. If  organisms  morphologically  similar  to  the  gonococcus  are 
discovered,  other  sUdes  that  have  not  been  in  water  are  placed  in  Lugol's 
solution  (iodin,  1  part;  potassium  iodid,  2  parts;  distilled  water,  300 
parts)  for  two  minutes.  They  are  then  transferred  to  absolute  alcohol 
for  exactly  thirty  seconds,  and  are  afterward  counter-stained  with  a 
solution  of  Bismarck  brown,  98  parts,  and  phenol,  2  parts. 

According  to  Neisser,'  the  period  required  for  decolorization  by 
Gram's  stain  is  dependent  upon  the  medium  in  which  the  gonococcus  is 
found.  Thus  it  is  said  that  gonococci  in  pure  culture  will  decolorize 
in  from  fifteen  to  twenty  seconds,  in  about  twenty  to  thirty  seconds 
when  in  pus,  and  in  one  minute  when  in  mucus.  The  thickness  of  the 
film  is  also  an  important  factor.  Occasionally  artificially  grown  gono- 
cocci retain  the  stain  for  a  long  time.  In  selecting  material  from  cul- 
tures for  staining  purposes  preference  should  be  given  to  young  colonies. 

Demonstration  of  Gonococcus  in  Dried  Secretion. — The  identifica- 
tion of  the  gonococcus  in  dried  secretion,  either  on  linen  or  on  clothing, 
is  under  certain  conditions  possible  even  after  prolonged  periods. 
This  point  is  sometimes  of  medicolegal  importance.  The  author 
agrees  with  Ledermann,-  who  states  that  although  it  is  possible  to 
show  gonococci  from  the  clothing  even  after  months  or  years,  such 
demonstration,  for  forensic  purposes,  should  be  received  with  extreme 
caution.  The  presence'  of  gonococci  is  proved  only  when  the  bacteria 
are  found  in  characteristic  grouping,  in  leukocytes,  when  there  is  a 
chance  for  counterstaining  with  Gram's  method,  and  when  the  organ- 
isms under  suspicion  correspond  morphologically  to  the  gonococcus. 
When  in  dried  secretion,  culture  methods  fail  almost  regularly,  as  the 
gonococcus  is  killed  by  prolonged  drying.  The  difficulty  of  positively 
identifying  the  gonococcus  in  dried  pus  can  be  readily  understood. 
Wachholz  and  Nowak'  found  micrococci  in  a  spot  of  dried  secretion  on 
the  skirt  of  a  girl  who  had  been  repeatedly  ravished.  Their  sup- 
position that  the  pus  was  from  a  gonorrhea  was  contradicted  by  the 
fact  that  neither  the  girl  nor  the  malefactor  had  gonorrhea.  Leder- 
mann,^ however,  beUeves  that  these  authors  go  too  far  when  they  state 
that  cultures  are  the  only  certain  method  by  which  gonococci  can  be 
positively  identified.     At  the  Second  International  Medical  Congress 

'  Neisser,  A.:  In  Kolle  u.  Wassermann,  Handbuch  f.  Bakt.,  1903,  vol.  iii. 
'  Ledermann,  R. :  Amer.  Jour.  Dermat.,  November,  1910,  vol.  xiv.  No.  11,  p.  51. 
'Wachholz  and  Nowak:   Vicrteljahressch.  f.  ger.  Med.,  1S95,  No.  9;   also  Schmidt- 
mann's  Handbuch  f.  gerichtliche  Medizin. 
'  Ledermann:  Loc.  cit. 


i 


BACTERIOLOGY    OF    THE    GONOCOCCUS  59 

in  Berlin,  in  1S90,  Kratter  reported  having  demonstrated  gonococci 
in  dried  secretion  by  the  following  method:  The  dried  secretion  was 
scraped  from  the  linen  and  soaked  for  a  short  time  in  water,  or  the 
threads  with  the  adherent  remnants  of  the  discharge  were  macerated 
and  squeezed  out.  The  gonococci  were  then  stained  by  the  usual 
method.  Haberda^  experimented  with  this  method.  'When  he  al- 
lowed a  very  thin  layer  of  pus  containing  gonococci  to  dry  on  clothing, 
he  could  show  the  microorganism  only  after  a  few  weeks.  In  thick 
layers,  of  which  minute  particles  could  be  gained,  gonococci  were  in 
evidence  after  eight  months.  But  the  characteristic  marks  had  dis- 
appeared, and  the  differential  diagnosis  from  other  diplococci  could 
not  be  made  with  certainty.  Even  worse  were  his  results  when  he 
investigated  material  from  chronic  gonorrheas  or  when  tUrty  linen  was 
used. 

Heger-Gilbert-  employed  the  following  method  with  better  success: 
A  small  linen  pad  or  piece  of  blotting-paper  moistened  with  isotonic 
salt  solution  (0.9  sodium  hydroxid  in  100  parts  of  water)  and  rendered 
alkaline  by  the  addition  of  sodium  bicarbonate  is  placed  in  a  watch- 
glass.  The  suspected  piece  of  linen  is  cut  out  and  laid  on  the  pad  and 
covered.  After  from  one  to  five  hours,  according  to  the  age,  thickness, 
and  dryness  of  the  specimen,  the  droplets  that  collect  underneath  are 
obtained  with  a  suction  pipet  and  placed  upon  a  slide,  dried,  and 
stained.  By  this  method  Heger-Gilbert  was  able  to  demonstrate 
gonococci  in  secretion  that  had  been  dried  for  two  j^ears. 

Examination  of  the  Urine  for  Gonococci. — In  dealing  with  hyper- 
sensitive women,  or  for  other  reasons,  it  may  be  necessary  to  attempt 
to  demonstrate  gonococci  in  the  urine.  If  this  is  the  case,  a  morning 
specimen  of  urine  .should  be  obtained,  the  patient  having  been  in- 
structed to  milk  out  the  urethra  with  the  finger  while  urinating.  The 
urine  shf)ul(l  be  allowed  to  stand  for  a  short  time  in  a  conic  urine  glass. 
The  sediment  should  then  be  centrifugalizcd  at  a  high  rate  of  speed 
(1200  involutions  a  minute)  for  three  minutes,  and  large  films  of  the 
pus  and  epithelial  debris  thus  collected  may  be  stained  in  the  manner 
previously  described.  If  a  large  amount  of  material  is  obtained  at 
the  first  centrifugation,  this  may  be  mixed  with  normal  salt  solution 
and  again  ccnti-ifugated,  under  which  circumstances  the  demonstration 
of  the  organism  is  somewhat  facilitated.  "Clap  shreds"  should  also 
be  examined.  Some  pathologists  object  to  the  use  of  the  centrifuge 
because  the  molecular  agitation  tends  to  break  up  and  destroy  the 
leukocytes  and  epithelial  cells,  and  thus  make  the  intracellular  demon- 

'  Haberda:  Quoted  by  I-cdcrmann:    Loc.  cit. 

'ircucr-dillicil:  Soc.  Hov.  dcs  .Sciences  M(;il.  ct  Natuiellcs  ilc  Htiixelles,  .luiic  1,  IHOS. 


60  GOISrORRHEA    IN   WOMEN 

stration  of  the  gonococcus  more  difficult.  Such  authorities  recom- 
mend collecting  the  sediment  in  a  conic  urine  glass  after  the  specimen 
has  stood  for  a  few  hours.  The  objection  to  the  use  of  the  centrifuge 
is  more  theoretic  than  practical.  Fresh  urine  should  be  employed 
for  cultures.  Urine  that  has  been  passed  for  some  hours  is  useless. 
It  must  be  borne  in  mind  that  gonococci  degenerate  quickly  in  urine, 
and  for  this  reason  atypical  forms  may  be  present  unless  the  urine  is 
fresh. 

Attempts  to  demonstrate  gonococci  in  the  urine  of  women  are 
usually  unsatisfactory,  and  can  be  viewed  only  as  makeshifts  until  a 
more  thorough  examination  can  be  perfornied.  Little  or  no  reliance 
can  be  placed  on  negative  findings. 

Although,  as  has  been  stated  elsewhere,  the  staining  character- 
istics previously  described  are  not  absolutely  diagnostic  of  the  gonococ- 
cus, they  are,  if  properly  carried  out  and  if  viewed  in  conjunction  with 
the  chnical  symptoms,  sufficiently  exact  for  all  practicable  purposes. 
The  decolorization  by  Gram's  method  is  certainly  the  most  character- 
istic staining  properly  possessed  by  the  gonococcus,  and  is  a  test  that 
should  never  be  omitted  in  differentiating  this  microorganism  from 
others  morphologically  similar.  In  examining  secretion  from  the 
female  genital  tract  gonococci  may  be  so  few  in  number  and  other 
microorganisms  so  numerous  that  the  diagnosis  is  extremely  difficult. 
If  this  is  the  case,  a  large  number  of  films  should  be  prepared  and 
stained. 

The  following  microorganisms  are  Gram  positive :  The  streptococ- 
cus, the  staphylococcus,  and  the  pyogenic  cocci  in  general,  yeasts, 
molds,  the  pneumococcus  of  Frankel,  the  Micrococcus  tetragenus, 
anthrax,  tetanus,  and  tubercle  bacilli,  the  bacteria  of  leprosy,  diph- 
theria, swine  erysipelas,  and  mouse  septicemia,  the  potato  bacillus, 
and  some  others. 

The  following  are  Gram  negative:  The  gonococcus,  the  Micrococ- 
cus melitensis,  the  Micrococcus  catarrhalis  (Pfeiffer),  the  typhoid 
bacillus,  the  Bacillus  coli  and  similar  bacteria,  cholera  and  similar 
vibrios,  the  bacillus  of  fowl  cholera,  rabbit  septicemia  and  malignant 
edema  (the  last  is  said  occasionally  to  remain  Gram  positive),  Fried- 
lander's  plague  bacillus,  the  glanders  bacillus,  the  bacillus  of  influenza, 
the  spirillum  of  relapsing  fever,  and  the  meningococcus. 

All  the  bacteria  in  the  first  list  may  be  excluded  by  the  proper 
application  of  the  Gram  stain.  Of  the  second  Ust,  the  Micrococcus 
meningitidis  and  the  Micrococcus  catarrhaUs  are  morphologically  very 
similar  to  the  gonococcus,  and  as  they  are  both  decolorized  by  Gram's 
stain,  they  cannot  be  excluded  by  this  method.     The  Micrococcus 


BACTERIOLOGY    OF    THE    GONOCOCCUS  61 

catarrhalis  is  slightly  larger  than  the  gonococcus,  but,  owing  to  the 
variability  in  size  of  the  latter,  little  significance  can  be  attached  to 
this  feature. 

The  Micrococcus  citreus  conglomerata  (Bumm^j,  the  Diplococcus 
albicans  amplus  (Bumm'),  the  Diplococcus  albicans  tardissimus 
(Bumm'),  and  the  Micrococcus  subflavus  (Bunim'),  are  all  morpho- 
logicallj'  somewhat  similar  to  the  gonococcus,  but  can  be  excluded  by 
Gram's  method.  Another  group  of  bacteria  usually  found  in  the 
sputum  and  nasopharyrrx,  and  which  are  saprophytic,  catarrhal-like 
organisms,  sometimes  cause  confusion.  These  have  been  described 
by  Elser  and  Huntoon,  who  term  them  the  chromogenic  Gram-nega- 
tive cocci.  Lingelsheim  has  studied  these  organisms  carefully  and 
gives  the  following  list : 

Micrococcus  pharyngeus  sicca  (Lingelsheim) ,  Micrococcus  pharyn- 
geus  cinereus  (Lingelsheim),  Diplococcus  pharyngeus  flavus  I  (Lin- 
gelsheim), Diplococcus  pharyngeus  flavus  II  (Lingelsheim),  and  the 
Diplococcus  pharyngeus  flavus  III  (Lingelsheim),  are  micrococci  that 
diff'er  from  the  Micrococcus  catarrhalis  only  in  the  amount  of  j'ellow 
pigment  they  contain. 

Fortunateh',  none  of  the  organisms  making  up  this  rather  formid- 
able list  of  Ciram-ncgative  bacteria  is  often  found  in  the  genital  tract, 
and  this  is  especially  the  case  in  the  male.  Nevertheless,  when  a 
positive  diagno.sis  is  required,  either  for  sociologic  or  for  medicolegal 
purposes,  other  means  than  staining  have  to  be  resorted  to.  For  these 
cases  cultures  ofTer  a  method  of  absolute  certainty  in  diagnosis. 

To  Bumm's'  indefatigable  labors  during  the  period  of  the  early 
history  of  the  gonococcus  are  we  indebted  for  much  of  our  knowledge 
regarding  the  growth  of  this  microorganism  on  artificial  media.  It 
may  be  stated,  at  the  outset,  that  the  cultivation  of  the  gonococcus 
in  the  laboratory  is  a  somewhat  difficult  procedure,  and  should  not 
be  attempted  without  special  technical  bacteriologic  training.  The 
attempted  diagnosis  of  gonorrhea  by  culture  methods,  unless  per- 
formed by  a  skilled  bacteriologist,  is  useless. 

Biology.  The  gonococcus  grows  best  at  Ijlood  temperature,  the 
extreme  limits  being  25°  to  40°  C.  The  optimum  temperature  is 
35°  to  37°  f ".  Unfortunately,  when  within  the  human  system  gono- 
cocci  are  more  resistant  to  variations  in  temperature.  Attempts  to 
cure  anterior  urethritis  of  gonorrheal  origin  by  means  of  dry  heat  or 
the  application  of  cold  have  not  met  with  much  success,  although  cold 
is  undoubtedly  a  valuable  adjunct  to  the  treatment  of  specific  ophthal- 

'  Umniii,  E. ;  iJcr  .Miknj-oi^aiii.simis  nuiiDiTluii.sclicii  Sclilciiiiliaut-Kikrankuiigi-n,  Wics- 
biuli'n,  188.1. 


62  GONORRHEA   IN   WOMEN 

mia,  but  probably  in  this  location  acts  as  much  by  relieving  congestion 
as  by  actually  inhibiting  the  growth  or  attenuating  the  microorganism. 
The  atmosphere  should  be  somewhat  moist.  The  organism  is  aerobic, 
and  possibly  slightly  facultative  anaerobic,  but  it  does  not  grow  along 
the  hne  of  puncture  when  stick  cultures  are  made  in  blood-serum. 
It  does  not  produce  spores,  and  is  strictly  parasitic,  its  habitation 
being  the  human  body.  The  gonococcus  is  often  associated  with  other 
organisms. 

Resistance. — When  left  at  room  temperature,  cultures  die  in  two 
or  three  days.  When  placed  in  the  ice-box,  they  may  live  for  several 
weeks,  but  usually  perish  moderately  quickly.  Gonococci  are,  how- 
ever, markedly  more  resistant  to  cold  than  are  cultures  of  the  meningo- 
coccus, which  are  always  killed  by  temperatures  approximating  0°  C. 
Gonococci  have  but  little  resistance  against  outside  influences,  and 
are  easily  destroyed  by  weak  antiseptic  solutions,  especially  those  that 
contain  silver  salts,  as  shown  by  the  work  of  Schaeffer  and  Steinschnei- 
der.^  Gonococci  in  pus,  when  smeared  on  linen  in  thick  layers,  has 
been  known  to  live  for  forty-nine  days  and  twentj'-nine  days  when  dried 
on  a  cover-glass.  Complete  desiccation,  however,  kills  in  a  short  time. 
According  to  Heiman,-  incompletely  dried  and  protected  from  the 
light,  as  in  the  case  of  pus,  the  gonococci  may  live  in  sheets  or  clothing 
for  a  considerable  period  of  time.  It  is  killed  in  six  hours  by  a  tem- 
perature of  45°  C,  and  in  thirty  minutes  by  a  temperature  of  60°  C. 
At  the  latter  temperature  its  virulence  is  destroyed  in  ten  minutes. 
Individual  strains  of  gonococci  exhibit  marked  variations  in  respect  to 
their  resistant  properties. 

Culture-media. — The  gonococcus  grows  sparingly  on  artificial 
media,  and  requires  for  its  best  development  the  addition,  to  nutrient 
agar,  of  a  small  amount  of  blood-serum  or  its  equivalent,  human  serum 
being  somewhat  better  than  that  obtained  from  the  lower  animals. 
After  having  been  subcultured  a  few  times,  the  amount  of  serum  may 
be  reduced,  and,  indeed,  with  some  strains  may  occasionally  eventually 
be  almost  entirely  eliminated.  The  native  protein  is  essential  for  the 
developmeiit  of  the  gonococcus.  The  soil  should  be  feebly  alkaline  or 
acid.  For  successful  growth  cultures  require  to  be  frequently  trans- 
planted. This  is  especially  important  at  first.  After  living  in  sub- 
cultures for  a  few  months  the  periods  of  subculturing  may  be  gradually 
lengthened.  Some  strains  under  such  circumstances  survive  for 
periods  of  three  or  even  six  weeks,  provided  the  proper  moisture  and 
temperature  are  maintained. 

'  Schaeffer  and  Steinschneider :   Kong.  Deut.  Dcrmat.  Gesell.,  Breslau,  1894. 

2  Heiman:  Studies  from  Path.  Lab.,  College  of  Phys.  and  Surg.,  New  York,  1895,  p.  3. 


BACTERIOLOGY    OF    THE    GONOCOCCUS  63 

The  great  number  of  culture-media  recommended  by  various  au- 
thorities shows  the  lack  of  an  ideal  medium.  Thalmann  obtained 
primary  cultures  (subcultures  failed)  on  his  agar.  Wildbolz^  suc- 
ceeded in  maintaining  a  growth  on  agar  after  several  subcultures  on 
serum-agar.  Vannon-  and  later  Martin^  isolated  and  maintained  a 
number  of  strains  of  gonococci  on  plain  agar.  WTien  gonococci  are 
successfully  cultivated  in  serum-free  media,  the  success  has  probably 
been  due  to  material  carried  o\-er  when  making  the  culture.  Subcultures 
usually  fail.  For  successful  cultivation  of  the  gonococcus  the  con- 
sensus of  opinion  is  that  a  preparation  of  uncoagulated  albumin,  de- 
rived from  either  man  or  animals,  is  an  essential  constituent  of  the 
medium.  Neither  hemoglobin  nor  urine  is  of  especial  service.  Mar- 
tin'' has  pointed  out  that  a  medium  most  rich  in  albumin  is  not  neces- 
sarily the  best,  whereas  small  amounts  of  human  serum  markedly 
accelerate  growth;  large  proportions  have  a  decided  bactericidal  ac- 
tion on  gonococci.  When  making  cultures,  surface  inoculations  are 
usually  the  most  successful,  as  gonococci  grow  best  in  the  presence  of 
free  oxygen.  The  culture  material  must  be  moderately  moist,  and 
for  this  reason  manj^  authorities  recommend  capping  the  tubes  or 
Petri  dishes  with  rubber  sheeting  during  incubation.  Below  follow 
the  details  of  the  method  of  preparation  of  a  few  media  that  have  given 
good  results: 

Bumrns  Solidified  Human  Blood-serum  (Abel''). — During  the 
course  of  a  normal  delivery,  when  the  cord  has  been  ligated  as  usual 
with  two  ligatures  and  severed  between  these,  the  placental  end  is 
disinfected  and  cut  through  above  the  proximal  ligature.  The  blood 
that  exudes  is  collected  in  a  sterile  flask.  This  vessel  is  allowed  to 
stand  for  twenty-four  hours  in  a  cool  place.  With  a  sterile  pipet  the 
separated,  clear  or  slightly  blood-stained  serum  is  then  removed  and 
filtered  into  sterile  test-tubes.  The  separation  of  the  serum  can  be 
facilitated  by  loosening  the  blood-clot  from  the  sides  of  the  vessel  with 
a  sterile  glass  rod  a  few  hours  after  the  blood  has  been  collected.  The 
scrum  may  be  converted  into  a  transparent  solid  medium  by  heating 
for  a  variable  time  at  about  70°  ('.,  the  test-tubes  being  slanted  in  the 
special  apparatus  tlesigned  for  this  j)urpose.  Although  every  effort 
may  have  been  made,  this  serum  is  frecjuently  not  sterile.     For  this 

'  Wildbolz,  I[.:  Ari-li.  f.  Dcmmt.  u.  .Sypli  ,  \i(iui:i  and  I.i  ip/JK,  IDOli,  vol.  Ixiv,  pp. 
22r>-264. 

^Viitinon:  Cont.  f.  Hakl.  u.  I'aiasitciik.,  vol.  .\1.  p.  HY>;  ibid.,  1907,  AM.  1,  orig.  vol. 
xliv,  p.  10. 

'  .Martin,  \\.  W.:  .Jour.  PaUi.  and  \',iu:\.,  July,  I'JIO,  p.  70. 
'  Martin,  W.  H.:   ]jOc.  cit. 

'  .\l)i'l,  R.:  Laboratory  Handbook  of  Bacteriology,  tran.slatcd  from  the  tenth  edition  by 
M.  II.  (lordon,  London,  r<)07. 


64  GONORRHEA    IN    WOMEN 

reason  it  should  be  sterilized  by  the  fractional  method  and  then,  to 
make  sure,  the  tubes  should  be  placed  in  the  incubator  for  twenty-four 
hours  and  those  eliminated  in  which  growth  takes  place. 

Another  method  is  to  pour  the  serum  into  medicine  bottles.  To 
these  add  plenty  of  chloroform.  Park  recommends  using  5  per  cent.; 
chloroform,  being  volatile,  tends  to  disappear  at  ordinary  tempera- 
tures, but  is  quickly  and  surely  driven  off  at  the  temperatures  used  in 
sterihzing.  Close  the  bottles  with  rubber  stoppers.  Store  for  several 
months,  at  the  expiration  of  which  time  the  serum  is  positively  germ 
free.  The  chief  disadvantage  of  this  method  is  the  time  required. 
Sterilization  by  filtration  is  a  tedious  and  unsatisfactory  method.  For 
most  purposes  the  transparency  of  the  serum  may  be  sacrificed,  for 
this  is,  as  a  rule,  of  no  great  value.  Sterilize  after  solidification  in 
slanting  tubes  by  heating  to  95°  or  98°  C,  for  one-half  hour  for  three 
successive  days,  or  the  material  may  be  heated  to  100°  C.  at  once. 
If  the  latter  is  done,  the  surface  of  the  medium  often  becomes  uneven, 
from  the  formation  of  bubbles.  In  whatever  way  prepared,  the  media 
should  be  tested  in  the  incubator  at  37°  C.  for  twenty-four  hours,  and 
all  test-tubes  that  show  contamination  eliminated.  If  it  is  desired, 
the  medium  may  be  allowed  to  solidify  in  Petri  dishes  and  sterilized  as 
just  described.  This  has  the  disadvantage  that  the  surface  of  the 
media  dries  quickly  and  extraneous  organisms  tend  to  find  access  to 
it.  Ascitic  or  hydrocele  fluid,  obtained  by  aseptic  puncture,  can  be 
used  in  place  of  the  serum.  The  reaction  is,  however,  sometimes  very 
alkaline  and  should  be  tested.  Should  the  placenta  have  been  ex- 
pelled, it  may  be  subjected  to  manual  pressure  and  the  blood  obtained 
in  this  way.  On  this  media,  when  solidified,  cultures  are  made.  The 
growth  is  not  luxuriant. 

Wertheim  Hwman  Blood-serum  and  Agar  Mixture  {Ahel^). — Each 
of  three  sterile  test-tubes  receives  1  c.c.  of  fluid  serum  (obtained 
as  just  described),  and  all  are  then  warmed  to  40°  C.  The  first  tube 
is  inoculated  with  gonococci;  from  it,  the  second;  and  from  that,  the 
third.  Two  c.c.  of  melted  agar  at  a  temperature  of  about  40°  C.  are 
then  passed  into  each  tube,  and  the  mixture  poured  out  at  once  into 
Petri  dishes  and  allowed  to  solidify.  Additional  suspected  material 
should  be  smeared  over  the  surface  of  the  solidified  plates.  It  is  then 
incubated.  The  colonies  are  larger  than  on  the  preceding  medium. 
This  is  one  of  the  best  media.  Some  authorities  believe  that  Wert- 
heim's-  medium  is  improved  by  the  addition  of  6  per  cent,  glycerin  or 
1  per  cent,  glucose. 

'  Abel:  Loc.  cil. 

-  Wertheim:  Arch.  f.  Derniat.  u.  Syph.,  1S99,  voL  xh,  No.  1. 


BACTERIOLOGY    OF   THE    GONOCOCCUS  65 

Keifers  Ascitic  Agar  (Abel^). — Neutral  meat-extract  agar,  con- 
taining 3.5  per  cent,  agar,  5  per  cent,  peptone,  2  per  cent,  glycerin, 
and  0.5  per  cent,  sodium  chlorid,  is  melted,  and  when  it  has  cooled  to 
50°  C,  is  mixed  with  an  equal  quantity  of  ascitic  fluid  (obtained  under 
aseptic  conditions),  and  allowed  to  sohdify  either  in  Petri  dishes  or 
in  slanted  tubes.  The  same  precautions  regarding  sterility  as  are  rec- 
ommended for  Bumm's-  medium  should  be  carried  out.  Surface 
cultures  are  made  on  this  medium.  If  the  ascitic  fluid  is  strongly  al- 
kaline, it  should  be  mixed  with  unneutralized  or  strongly  acidified  agar 
solution,  so  that  the  mixture  will  be  rendered  slightly  alkaline.  Aleyer^ 
employed  this  medium  in  90  cases,  and  was  able  to  cultivate  the  gono- 
cocci  in  87  cases ;  in  onlj'  58  of  these  cases  was  it  possible  to  demonstrate 
the  microorganism  in  the  secretion  by  means  of  the  microscope. 

Abel's*  Blood-smeared  Agar. — The  finger  or  some  other  por- 
tion of  the  skin  is  disinfected  and  then  washed  in  sterile  water  to  rid 
it  of  the  antiseptics.  A  puncture  is  then  made,  and  the  blood  thus 
obtained  is  smeared  on  the  surface  of  nutrient  agar.  The  test-tubes 
should  be  stoppered  with  sterile  cotton.  Surface  cultures  are  made  by 
taking  a  small  quantity  of  the  suspected  secretion  on  the  end  of  a 
sterile  camel's-hair  brush  and  rubbing  this  up  with  a  drop  of  sterile 
blood.  The  mixture  on  the  brush  is  then  smeared  over  the  surface  of 
the  medium  after  having  first  made  sure  of  the  sterility  of  the  latter. 
This  medium  is  reconmiended  for  subcultures  chiefly  because  it  is  easy 
to  prepare.  The  first  generation  does  not  always  grow  upon  it.  Cole 
and  Meakins  have  had  excellent  results  with  this  medium. 

Wright's  Modification  of  Steinschneider' s  Method.'-' — The  details  of 
the  method  as  given  by  Wright  are  as  follows:  "A  liter  of  nutrient 
agar  is  prepared  in  the  usual  manner,  and  after  filtration  it  is  evapo- 
rated to  about  000  c.c.  This  concentration  is  desirable,  so  that  after 
dilution  with  the  urine  and  serum  the  medium  may  be  sufficiently  firm. 
This  concentrated  agar  is  then  run  into  test-tubes,  and  the  whole 
sterilized  by  steam  on  three  successive  days.  The  quantity  of  agar 
placed  in  each  tube  is  smaller  than  is  usual;  this  is  in  order  to  allow  for 
the  subscfiuent  addition  of  the  urine  and  serum. 

"The  i)lood-serum,  which  need  not  be  free  from  corjjuscles,  is  first 
passed  through  white  sand,  which  is  supported  in  a  funnel  by  filler- 
paper,  in  order  to  remove,  as  far  as  possil^le,  anj'  particles  in  suspen- 
sion, and  is  then  mixed  with  half  its  volume  of  fresh  urine.     The  mix- 

'Abcl:  Loc.  cit. 

'Buram,  E.:  Dcr  Mikro-DiKuiiisiiiusuDiiorrhoisi'licriSi-lili'imluiul-lMkniiikuMKi'M,  Wics- 
badon,  188.5. 

'Meyor:  Deutseli.  nicd.  Woch.,  l(tf«,  vol.  xxix,  \o.  :!('..  *  Al)cl:  Loc.  cil. 

''Wripht:(2iiol("ill>yA.C'..Vl)l)olt;I'riMcii)l(>sof  liiicterioIoKy.riKhtlMilitioii.lOO!),  t).2!)0. 


gg  GONORRHEA   IN  WOMEN 

ture  of  urine  and  blood-serum  is  next  filtered  by  suction  through  an 
unglazed  porcelain  cylinder  into  a  receiving-flask,  such  as  chennsts 
use  for  sinnlar  purposes,  by  means  of  a  water-vacuum  pump,  ihis 
frees  the  mixture  from  bacteria. 

"The  usual  precautions  are,  of  course,  taken  to  prevent  the  con- 
tamination of  the  filtrate,  such  as  the  previous  sterilization  by  steam 
of  the  cylinder  and  receiving-flask,  besides  others  wliich  will  occur  to 

any  bacteriologist.  ,        ,     .     .  . 

"To  the  agar  in  each  test-tube,  which  is  flmd  and  of  a  temperature 
of  about  40°  C  ,  there  is  added  about  one-third  to  one-half  its  volume 
of  the  filtered  mixture  of  urine  and  blood-serum.  This  is  conveniently 
accomplished  by  pouring  the  mixture  from  the  receiving-flask  through 
the  lateral  tube,  inserted  near  its  neck  dhectly  into  the  tubes,  ihe 
prehminarv  melting  of  the  agar  is  best  effected  in  the  steam  sterilizer, 
in  order  that  any  organisms  which  have  found  lodgment  in  the  cotton 
plugs  of  the  tubes  may  be  destroyed,  men  the  agar  is  melted  it  is 
cooled  and  kept  fluid  by  placing  the  tubes  in  a  water-bath  at  40  L. 
Each  tube,  after  the  addition  of  the  urine  and  serum  to  the  fluid  agar, 
is  quickly  shaken  to  insure  a  uniform  mixture,  and  is  then  placed  in  an 
inclined  position  to  allow  the  agar  to  solidify  with  a  slanting  surface. 
When  the  medium  in  the  tubes  has  sohdified,  the  tubes  are  placed  in 
the  incubator  for  about  twenty-four  hours  to  test  for  contaminations, 
after  which  they  are  ready  for  use." 

Naka-Abc  Serum  Mediu^n. -Tins  serum  is  made  by  macerating  500 
grams  of  beef  with  1  liter  of  water  for  twenty-four  hours  ^  the  ice- 
chest      This  is  then  filtered  through  a  Chamberland  filter.     The  fluid 
is  flasked  and  kept  for  four  weeks,  during  which  time  its  bactericidal 
portions  are  destroyed.     It  is  then  added  to  plain  agar,  in  the  propor- 
tion of  1  to  2      The  originator  claims  excellent  results  for  tlus  medium, 
and  asserts  that  the  growth  is  always  visible  in  eighteen  hours.     _     ^ 
Wassermann's'  Nutrose  Medium.— Mix  in  a  flask  lo  c.c.  of  swine  s 
blood  30  to  40  c.c.  of  water,  2  to  3  c.c.  of  glycerin,  0.8  gram  of  nutrose, 
and   while  constantly  shaking  the  mixture,  boil  for  fifteen  minutes. 
Repeat  boiling  and  shaking  on  following  day.     This  fluid  may  now  be 
stored.     Before  using,  heat  to  50°  to  60°  C,  and  mix  with  an  equal 
quantity  of  sterile  2  per  cent,  peptone-agar.     This  medmm  is  excel- 
lent for  surface  subcultures.  ,       ^      . 
Thalmann's  Meat-extract  Agar  (A 6eJ=) .-Prepare  meat  extract 
follows-    Take  500  grams  of  finely  chopped  beef,  as  free  from  1  at  aj 
possible,  warm  in  a  pot  with  one  liter  of  water  to  50°  C,  at  which  ter- 

■      1  Wassermann:  Zeit.  f.  Hygiene,  1S97,  vol.  xxvii;  also  Berlin,  klin.  Woch.,  1897,  No.  32. 
=  Abel:  Loc.  cil. 


BACTERIOLOGY    OF    THE    GONOCOCCUS  67 

perature  it  should  be  kept  for  thirty  minutes.  Then  boil  for  from  one- 
half  to  three-fourths  of  an  hour.  Strain  off  the  fluid  from  the  meat. 
Add  enough  water  to  make  one  hter  and  then  run  into  a  flask,  the 
mouth  of  which  should  then  be  stoppered  with  cotton.  If  this  is  to  be 
preserved,  it  should  now  be  sterilized  by  the  fractional  method,  or  by 
exposing  it  in  an  autoclave  to  a  temperature  of  100°  C.  for  fifteen  min- 
utes. To  this  solution  add  1.5  to  2  per  cent,  of  finely  chopped  agar. 
Two  hours  later,  when  the  agar  has  become  softened,  add  0.5  to  5  per 
cent,  of  common  salt.  Heat  gently  in  a  steamer  until  agar  is  dissolved. 
Nearly  neutralize  with  phenolphthalein.  The  acidity  of  the  mixture 
must  usually  be  reduced  about  two-thirds  to  three-fourths  by  the 
addition  of  caustic  soda.  The  method  of  neutraUzation  with  phenol- 
phthalein is  as  follows:  Place  5  c.c.  of  the  medium  in  a  flask,  dilute 
with  45  c.c.  of  freshly  prepared  distilled  water,  and  boil  for  three  min- 
utes over  a  flame.  Now  add  1  c.c.  of  phenolphthalein  (0.5  gram  phenol- 
phthalein in  100  c.c.  of  50  per  cent,  alcohol)  and  titrate  with  hj^dro- 
chloric  acid  until  the  fluid  develops  a  red  color.  Add  to  the  remainder 
of  the  medium,  according  to  the  result  of  this  titration,  experimental 
normal  sodium  hydroxid  or  normal  hydrochloric  acid  until  the  reaction 
is  neutral.  Then  titrate  again  a  sample  of  the  medium  (5  c.c.)  as 
directed  above,  and  correct  the  reaction  of  the  remainder,  if  necessarj'. 
Heat  to  boiling  and  test  again.  If  the  medium  is  now  neutral  or  shghtly 
alkaline  to  phenolphthalein,  it  is  strongly  alkaline  to  litmus,  since 
the  peptone  or  diphosphate  present  in  the  medium  is  neutral  or  al- 
kaline to  htmus,  but  acid  or  neutral  to  phenolphthalein.  As  media 
are  more  suitable  for  bacterial  growth  when  neutral  or  slightly  alkaline 
to  litmus,  media  neutral  to  phenolphthalein  must  receive  an  addition 
of  acid.  Thus  from  1.5  to  2.5  per  cent,  of  hydrochloric  acid  (note  how 
much)  is  added,  and  the  mixture  boiled,  filtered,  and  steriUzed.  For 
subcultures  Thalmann  reconnnends  broth  of  similar  reaction,  or  a 
serum  may  be  made  by  mixing  such  broth  with  sterile  scrum  in  equal 
parts  and  allowing  it  to  solidify. 

Lipschiilz's^  Eg(j-nlhuimn  Agar  Culture-medium. — To  3  parts 
ordinary  peptone  agar  or  broth  add  one  part  alkaline  2  per  cent,  egg- 
alhunien  solution.  Merck's  finely  powdered  egg-albumen  is  recom- 
mended by  Lipschiitz.  This  is  readily  soluble  in  water.  The  albu- 
min solution  may  be  filtered  and  sterilized  before  adding  the  agar  to  it. 
This  medium  is  easily  made,  and  the  albumin  can  be  obtained  without 
difficulty.  The  originator  of  the  method  states  that  he  has  grown 
gonococci  in  this  medium  to  the  thirty-fifth  generation. 

'  Lipschiitz:  Cent.  f.  Bakteriologie,  1904,  vol.  xxxvi. 


gg  GONORRHEA   IN   WOMEN 

Baer's^  Medvum.-Baev  recommends  the  following  medium.  Hy- 
drofdeplem-itic,  or  ascitic  fluid  is  collected  under  aseptic  condi  ions 
in  sterie  flasks.  This  is  placed  in  test-tubes  and  tested  f or  stenhty  m 
the  t  ubator  for  twenty-four  hours  at  37°  C.  All  tubes  that  exhibit 
Irowth  are  discarded.  The  sterile  transudate  is  then  mixed  with 
Sai"  agar  that  has  been  previously  condensed  to  two-thirds  of  its 
ulk  in  tiie  proportion  of  one  part  of  transudate  to  two  parts  of  agar. 
The  t  Ludatel  added  to  the  agar  in  test-tubes,  the  agar  having  b^en 
melted  and  cooled  to  45°  C.  The  tubes  thus  prepared  are  capped  with 
Irle  rubber  and  allowed  to  solidify  in  a  slantmg  position.  The 
medmnlthentestedforste^ 

?Ws  medium  is  used  for  surface  cultures.  The  condensed  water  m 
le  tXs  assists  in  spreading  the  suspected  secretion  over  the  surface^ 
BowhilVs"'  MediuM.-^A  good  liquid  medmm,  recommended  by 
Bowhill  may  be  prepared  by  mixing  1  part  of  human  blood-serum  with  . 
9  par  sofpeptone  bouillon.  In  this  medium  the  gonococci  form  a 
membrane  on  the  surface,  whereas  the  medium  itself  remains  almost 
Sely  clear.  In  preparing  this  medium  animal  blood-serum  may 
bf  Substituted  for  human  serum,  although  the  toiler  is  the  better.  . 
Nevertheless,  gonococci  grow  quite  well  on  swine  blo-l.er-m 

Heiman^  Chest  Semm.-Pleuritic  or  hydrothorax  A^^^/^  f  «™- 
To  this  is  added  2  per  cent,  agar  broth,  1  pex  cent,  peptone,  wi  h  o 
without  0  5  per  cent.  salt.  Heiman  beheves  that  the  excellence  of  this 
ni^dium  for'the  cultivation  of  gonococci  is  due  to  the  large  amount  o 
a  bui^n  which  it  contains.  Other  fluids  that  may  be  substituted  for 
th  c'e  ttid  are  peritoneal  fluid,  chronic  synovitis  effusion,  hydrocele 
tld  pericardial  fluid,  the  fluid  contents  of  ovarian  cysts,  and  hydro- 
salpinx fluid.     Heiman,  however,  prefers  the  chest  serum^ 

Martin's^  Medium.-Beef-extract  is  prepared  in  t^e  usual  manner 

To  it  are  added  0.5  per  cent,  of  disodium  f^'^'^'Flt^Tt)^- 
cent  of  Witte's  peptone,  and  2  per  cent,  of  powdered  agar  The  nnx 
ture  is  pLed  in  a  Koch  steriUzer,  and  after  the  agar  has  been  melted 
and  wtS^e  still  hot,  the  medium  is  titrated.  For  this  purpose  5  c.c.  o 
the  sample  medium  is  taken,  to  which  are  added  two  drops  of  0.5 
per  ceTtBolution  of  phenolphthalein ;  normal  sodium  hydroxid  solu- 
tion  is  added  from  a  buret  until  a  faint  but  perman^n  pink  color 
Xch  c^stinctly  deepens  on  cooling,  appears.  This  is  taken  as  th 
Ind  point,  and  if  the  medium  is  of  the  correct  degree  of  acidity  (0.6 


1  Baer:  Jour.  Infec.  Diseases,  1904,  vol  iv,  PP- 313-326. 

2  Bowhill:  Manual  of  Bact.  Tech.  and  Special  Bact.,  N.  Y.,  190-,  p.  -4. 

3  Heiman,  H.:  Med.  Record,  N.  Y.,  vol.  In.,  p  80^ 

4  Martin,  W.  B.:  Jour.  Path,  and  Bact.,  July,  1910,  p.  76. 


I 


BACTERIOLOGY    OF   THE    GONOCOCCUS  69 

per  cent,  to  phenolphthalein  or  +  6  on  Eyre's  scale),  0.6  c.c.  of  soda 
solution  will  have  been  used  (in  the  proportion  noted).  In  practice, 
however,  more  alkali  is  at  first  required.  For  example,  if  2  c.c.  were 
used,  then  the  medium  is  1.4  per  cent,  to  acid.  This  is  corrected  by 
adding  to  the  medium,  in  bulk,  normal  sodium  hydroxid  solution  in  the 
proportion  of  1.4  c.c.  to  each  100  c.c.  of  medium  (usually  somewhat 
more  than  the  calculated  figure  is  actualh'  requisite).  The  reaction 
having  been  adjusted,  the  medium  is  filtered,  tubed,  and  sterilized  as 
usual.  Care  should  be  taken  to  avoid  prolonged  cooking,  as  this 
causes  a  darkening  of  the  medium,  and  increases  the  difficulty  of 
titration.  If  white-of-egg  has  been  used  for  clearing  purposes,  allow- 
ance must  be  made  for  the  fact  that  it  is  usually  more  acid  than  the 
medium.  TMien  properly  prepared,  the  medium  is  nearly  colorless 
and  should  possess  only  a  moderate  amount  of  water  condensation. 
For  use:  On  the  surface  of  each  slanted  test-tube  three  or  four  drops 
of  sterile  (exposed  to  57°  C.  for  one  and  one-half  hours)  human  blood- 
serum,  obtained  under  aseptic  conditions,  are  placed.  The  tubes  are 
then  tested  overnight  in  the  incubator,  to  make  certain  that  they  are 
still  sterile.  In  case  of  plates,  the  serum  is  added  to  the  agar  after  it 
has  been  melted  and  cooled  to  45°  C,  in  the  proportion  of  0.2  c.c.  of 
serum  to  5  c.c.  of  medium.  To  avoid  drying,  the  test-tubes  should  be 
capped  with  sterile  rubber.  As  gonococci  are  sensitive  to  room- 
temperature,  it  is  best  to  make  inoculations  direct  from  subject  to 
medium  in  the  incubator  when  possible.  After  isolation  it  is  advisable 
to  make  frequent  subcultures  to  maintain  recent  strains.  ^Martin 
prefers  to  isolate  by  means  of  stroke  cultures  rather  than  by  shake 
plates,  although  in  articular  effusions  the  latter  method  is  better,  the 
centrifugatod  fiuid  being  used.  This  medium  has  the  advantages  of 
transparency,  economy  of  scrum,  and  is  suitable  for  cither  plates  or 
slanted  tubes. 

Duval's  Method  of  PreimriiKj  Blood  Agar.  \  base  of  2  per  cent. 
agar  is  prepared;  ])(>ptone,  1  per  cent,  and  sodium  chlorid,  0.5  per  cent., 
are  added  to  beef  infusion.  This  is  corrected  to  0.6  per  cent,  acid  to 
phenolphthalein  (hot  titration)  before  sterilizing  in  the  autoclave. 
To  the  tubed  sterile  agar,  melted  and  cooled  to  a  temperature  of  52° 
C,  is  added  a  small  quantity  of  sterile  defibrinated  human  blood. 
From  4  to  7  drops  of  blood  are  added  to  each  6  to  10  c.c.  of  agar.  The 
tubes  are  then  shaken  and  slanted,  or  the  contents  poured  into  Petri 
dishes.  By  this  means  a  beautiful,  bright  crimson,  almost  trans- 
parent, inodium  is  oljtaiiied,  possessing  a  moderate  aniovmt  of  water  of 
condeiisatidii.  If  llic  agar  is  hotter  tluui  60°  ('.,  when  the  blood  is 
added,  the  liciiiiigl(il)in  is  dcst  foycd  and  a  (hrty  bi-owii  mixluic  is  tiii- 


70  GONORRHEA    IN    WOMEN 

result.  If  the  agar  is  too  cool,  there  will  be  no  water  condensation. 
This  medium  is  improved  by  keeping  it  for  one  to  two  weeks  before 
using.  The  tubes  may  be  stoppered  with  rubber  or,  better,  with 
paraffined  corks.     This  medium  is  recommended  by  Gurd.^ 

Thalhimer^  recommends  the  following  for  a  simple  laboratory 
method:  Freshly  drawn  beef  blood,  obtained  from  an  abattoir,  is  col- 
lected in  a  wide-mouthed  jar  and  defibrinated  by  shaking  with  a  num- 
ber of  medium-sized  marbles.  This  is  laked  by  adding  an  equal  part 
of  distilled  water  and  rendered  free  from  bacteria  by  means  of  a  Reichel 
filter.  The  filtrate  should  be  a  clear  red  fluid.  From  20  to  30  c.c.  of 
this  are  added  to  1  liter  of  sterile  melted  agar  at  45°  C,  and  the  result- 
ing mixture  is  then  poured  into  sterile  tubes.  The  medium  that  results 
is  perfectly  clear,  bright  red,  and  of  the  same  shade  as  ordinary  blood- 
agar.  On  this  medium  organisms  that  were  unsuccessfully  tested  on 
hemoglobin  agar  were  successfully  passed  through  a  number  of  gen- 
erations. Gonococci  grew  luxuriantly.  This  method  is  a  modifica- 
tion of  former  methods,  notably  that  of  Pfeiffer,  and  is  believed  to  be 
the  simplest  yet  devised  for  preparing  blood-agar.  It  is  evident  that 
the  hemolytic  quaUties  of  an  organism  cannot  be  tested  with  this 
medium. 

Youncfs^  Media.— Sterile  hydrocele  or  ascitic  fluid  obtamed  by 
modern  surgical  methods  is  mixed  with  nutrient  agar.  A  number  of 
common  agar  slants  are  put  in  the  autoclave  for  five  minutes.  This 
liquefies  the  agar  and  sterilizes  the  tubes  and  cotton  stoppers.  The 
slants  are  then  put  in  a  water-bath  at  55°  C.  The  stopper  having 
been  taken  from  a  small  flask  of  hydrocele  fluid,  the  top  of  the  flask  is 
flamed  and  the  fluid  then  poured  on  an  agar  tube,  the  top  of  which  has 
been  flamed,  in  proportions  a  httle  more  than  one  to  two.  The  agar 
tube  is  then  stoppered  and  slanted.  When  plate  cultures  are  to  be 
used,  sterile  tubes  containing  about  7  c.c.  of  hydrocele  fluid  are  em- 
ployed. These  are  inoculated  and  mixed  with  melted  agar  slants  at  a 
temperature  of  40°  C.,  the  two  being  poured  separately  into  a  Petri 
dish.  Young  prefers  the  slant  method,  and  has  kept  gonococci  alive 
on  these  for  three  months.  The  hydrocele  or  ascitic  fluid,  if  uncon- 
taminated,  may  be  kept  for  several  months  before  use. 

According  to  some  writers,  human  urine,  steriUzed  by  filtration 
through  porcelain  and  added  to  a  mixture  of  blood-serum  and  agar, 
facihtates  the  growth  of  th*e  gonococcus.  Cultures  have  also  been 
grown  on  acid  gelatin,  gelatin  containing  acid  urine,  in  acid  urine  itself, 

1  Gurd:  Jour.  Med.  Research,  1910,  vol.  xxiii;  n.  s.,  vol.  xviii,  p.  154.  ■ 

=  Thalhimer,  W.:  Bull.  Johns  Hopkins  Hospital,  August,  1911,  p.  293. 

■■>  Young,  H.  H.:  Contributions  to  the  Science  of  Medicine,  Baltimore,  1900,  p.  677. 


I 


BACTERIOLOGY    OF    THE    GONOCOCCUS  71 

and  in  albuminous  urine  with  agar.  These  media  are,  however,  un- 
certain and  of  doubtful  value. 

Reaction  of  Culture-media. — This  detail  is  of  the  greatest  impor- 
tance, and  inattention  to  it,  or  different  testing  methods  employed, 
doubtless  accounts  for  the  many  varjdng  results  obtained  by  cUfferent 
investigators  in  the  cultivation  of  the  gonococcus.  Finger,  Ghon,'  and 
Schlagenhaufer  (1894)  postulated  a  reaction  frankly  acid  to  litmus 
as  essential.  Thalmann"  (1900)  laid  the  optimum  reaction  between 
neutrality  to  litmus  and  neutrahty  to  phenolphthalein.  Vannon^ 
prepared  a  medium  faintly  alkahne  to  litmus,  and  finally  Gurd^  pro- 
posed a  medium  of  the  reaction  of  0.6  per  cent,  acid  phenolphthalein, 
whereas  Pollock  and  Harrison^  recommend  a  reaction  of  -t-  6  Eyre's 
scale.  Until  comparatively  recently  litmus  was  the  most  generally 
u.sed  indicator  for  neutralizing  media,  adding  normal  sodium  hydroxid 
solution  until  red  litmus  turned  slightly  blue  or  blue  Utmus  a  shade  less 
blue.  Phenolphthalein  is  a  much  more  accurate  and  sharper  indicator 
than  litmus,  and  has  the  advantage  of  being  colorless  in  acid  solution 
and  pink  in  alkahne.  It  should  be  remembered  that  different  indica- 
tors varj'  not  only  in  delicacy,  but  react  differently  to  various  sub- 
stances. A  medium  that  is  alkaline  to  litmus  may  be  acid  to  phenol- 
phthalein, showing  that  there  is  present  in  such  mixtures  an  acidity 
that  litmus  does  not  detect.  These  substances  are  organic  compounds 
or  acids,  theoretically  amphoteric,  but  in  which  the  acid  character 
predominates.  Thus  a  hter  of  bouillon  becomes,  on  the  addition  of  1 
per  cent,  peptone,  more  alkaline  to  litmus,  but  decidedly  more  acid  to 
phenolphthalein.  In  cultivating  the  gonococcus  the  reaction  of  the 
medium  is  of  the  greatest  importance,  and  for  this  reason  tests  by 
phenolphthalein  should  always  be  resorted  to.  In  using  phenolphthal- 
ein care  must  be  taken  to  eliminate  the  effects  of  carbon  dioxid,  which 
is  acid  to  phenolphthalein.  For  convenience  sake  titrations  of  media 
should  be  made  as  nearly  100  c.c.  as  possible.  All  media  should  in- 
variably be  tested  for  twenty-four  hours  in  an  incubator  at  37°  (\, 
iinincdiatcly  prior  to  its  use,  to  ascertain  its  sterility. 

Appearance  of  Colonies. — Colonies  of  gonococci  can  usually  Ik'  de- 
tected macroscopically  at  the  end  of  twenty-four  hovu's;  however, 
gonococci  vary  somewhat  in  the  speed  with  which  they  develop  col- 
onies, and  for  this  reason  it  is  advisable  to  incubate  suspected  cultures 
for  at  least  three  days  unless  a  growth  is  obtained  prior  to  this  time. 

'  Ohon,  PfcifTer,  ami  Sederl :  Zeit.  f .  klin.  Med.,  1902,  vol.  xl.  '  Tluvliiiaiin :  Loc.  cit. 

•  Vnnnon:  Cent.  f.  »;ikt.  ii.  Piini.sitonk.,  vol.  xl,  p.  102;  ibid.,  1907,  1.  Aljt.,  orig.  vol. 
xliv,  p.  10. 

'  (liinl:  Lnc.  ril. 

'  Pollock,  C.  K.,  :iiiil  lliirrison,  L.  W.:   (loiiocorcal  Iiifcrlions,  London,  1912. 


72  GONORRHEA   IN   WOMEN 

As  a  general  rule,  it  may  be  stated  that  gonococci  grow  slowly  on  arti- 
ficial media,  and  that  a  delicate  growth  is  characteristic.  Colonies 
are  usually  small.  Their  appearance  varies  somewhat  with  the  me- 
dium on  which  they  are  cultivated.  In  color,  the  colonies  are  grayish- 
white,  opalescent,  with  often  a  tinge  of  yellow,  especially  toward  the 
center.  At  the  end  of  twenty-four  hours  they  usually  appear  as  small, 
isolated,  circular,  raised,  translucent,  finely  granular  colonies,  the  edges 
of  which  are  scalloped  or  crinkled.  The  margins  appear  to  fade  grad- 
ually into  the  surrounding  culture-medium.  The  granular  appearance 
is  particularly  noticeable  toward  the  periphery.  In  the  center,  small 
grayish  or  yellowish  punctate  spots  of  high  refraction  are  often  seen. 
Surface  streak  cultures  usually  appear  as  translucent,  granular,  gray- 
ish-white growths  with  rather  well-defined  thick  edges.  At  the  end 
of  three  days  colonies  frequently  measure  only  1  or  2  mm.  in  diameter. 
Under  careful  cultivation  on  suitable  medium,  colonies  may,  however, 
attain  a  diameter  of  1  or  2  cm.  Cultures  grown  on  the  Wertheim^  me- 
dium, at  the  end  of  twenty-four  hours  appear  as  previously  described. 
The  superficial  colonies  exhibit  a  dark  spot  in  the  center,  from  which 
a  delicate,  finely  granular  coating  extends  arovuid  the  colony.  The 
deeper  colonies  are  grayish-white  and  present  an  uneven  appearance. 
At  the  end  of  two  or  three  days  they  acquire  somewhat  the  shape  of  a 
blackberry,  whereas  on  the  surface  there  is  a  moist,  yellowish  growth, 
from  the  border  of  which,  under  the  low  power,  small  processes  may  be 
seen  extending.  At  this  stage  such  cultures  must  be  transplanted  or 
the  colonies  are  likely  to  perish.  In  reinoculating  from  the  colonies 
they  are  found  to  consist  of  shining,  tenacious,  compact  masses. 
Stroke  cultures  on  oblique,  solidified  blood-serum-agar  (Wertheim-) 
produce  moderately  luxuriant  growths.  At  first  these  appear  as 
isolated,  grayish  colonies,  which  later  become  moist,  slimy,  and  tena- 
cious, and  from  the  margins  of  which  a  film-like  coating  extends. 
Gonococci  do  not  hquefy  blood-serum.  Growth  on  Martin's'  medium 
appears  in  from  eighteen  to  twenty-four  hours.  The  colonies  are 
minute,  semitransparent,  slightly  elevated  discs,  presenting  to  the 
naked  eye  a  moist,  glistening  surface.  By  low  power,  with  transmitted 
fight,  they  appear  almost  transparent,  and  are  a  light  grayish  yellow. 
They  are  homogeneous,  the  ground-substance  being  finely  granular. 
They  have  definite  uniform  margins,  which,  with  the  high  power,  are 
seen  to  be  slightly  toothed.  As  the  colonies  enlarge  they  tend  to  re- 
main discrete;  the  center  thickens  and  becomes  more  opaque,  owing 
to  the  development  of  numerous  ovoid,  coarse  granules.     At  the  end  of  j 

'  Wertheim:  Arch.  f.  Derm.  u.  Syph.,  1S99,  vol.  xli,  No.  1.  ■  Wertheim:  Lnc.  cil. 

»  Martin.  W.  B.:   .lour.  Path,  and  Bact.,  July,  1910.  p.  76. 


BACTERIOLOGY    OF   THE    GONOCOCCUS  73 

from  fortj'-eight  to  seventy-two  hours  the  margins  are  scalloped. 
Thus  radial  striations  develop,  and  concentric  rings,  due  to  different 
zones  of  opacitj',  also  appear.  Finally,  when  about  a  week  old,  coarser 
granules  become  visible.  These  are  often  so  white  and  opaque  in 
contrast  to  the  remainder  of  the  colony  as  to  suggest  contaminations. 
The  growths  may  readily  be  removed  on  a  platinum  loop,  and  are  dis- 
tinctly viscous  in  consistence,  although  neither  slimy  nor  tenacious. 
On  Duval's  medium  colonies  can  be  macroscopically  distinguished  in 
from  eighteen  to  twenty-four  hours,  occasionally  being  delayed  for 
forty-eight  hours,  ^^^len  the  colonies  are  fully  developed  they  appear 
as  watery-looking,  bluish  gray  or  almost  colorless,  semitransparent, 
small,  round  excrescences  having  a  fairly  well-developed  outline. 
At  the  end  of  seventy-two  hours  colonies  show  a  tendency  to  spread 
from  the  periphery  in  a  somewhat  irregular  manner. 

In  old  cultures  the  appearance  of  the  colones  varies  widely.  At 
times  they  may  be  found  to  be  simply  a  mass  of  more  or  less  Gram- 
negative  material.  Heiman^  has  maintained  a  culture  for  three 
months,  but  this  is  an  exceptionallj'  long  period  for  a  culture  to  exist 
without  transplanting.  As  a  rule,  they  die  in  a  much  shorter  period. 
The  morphology  of  the  individuals  of  very  old  colonies  often  in  no 
way  resembles  ordinary  gonococci.  Nevertheless,  such  material  re- 
inoculated  on  suitable  culture-medium  may  produce  gonococci  that 
are  typical  in  mode  of  growth,  staining  reaction,  morphology,  and  in 
pathogenic  character.  A  successful  inoculation  from  a  culture  of  the 
twelfth  generation  was  performed  by  Aufuso.  A  similar  result  was 
obtained  by  Buniin  from  the  twentieth  generation. 

Method  of  Testing  Colonies. — (1)  Films  may  be  prepared  and 
stained  with  the  ordinary  stains  and  by  Gram's  method.  Few  cocci 
other  than  the  gonococci  are  Gram-negative.  (2)  Subcultures  should 
be  made  on  ordinary  agar.  If  the  organism  is  the  gonococcus,  there 
is  no  growth.  (This  applies  only  to  freshly  isolated  cultures.  Oc- 
casionally certain  strains  of  gonococci  will  be  encountered,  which, 
after  having  Vjeen  grown  on  artificial  media  for  a  number  of  gen- 
erations, seem  to  adapt  themselves  to  their  surroundings  and  will 
thus  grow  on  ordinary  laboratory  media.)  There  is  no  growth  on 
gelatin. 

Animal  Experimentation. — The  gonococcus  is  strictly  parasitic 
'Hutrnii  ),  and  seems  to  attack  man  exchisivel}',  for  gonorrhea  cannot 
be  |)ri((luc('<i  ill   the  iowci-  aniinMJs.     Kxcii   tlie  aiithi'dpoid  apes   ai'i' 

'  Ilcirnaii:  Studies  from  ilii'  l':illi.  Lai).,  C'olloKC  I'liysician.s  and  Siiincons,  Niw  York, 
189.5,  p.  :i. 

'  Hiiiniii:  Wit's  Handliiiili  dcr  ( lynakolo(tip,  vol.  ii. 


74  GONORRHEA   IN   WOMEN 

immune  to  this  disease  (Wildbolz^).  Neisser  inoculated  dogs,  with 
negative  results.  Loffler  and  Leistikow^  inoculated  the  abraded  con- 
junctiva and  urethra  of  rabbits  and  guinea-pigs  without  result. 
Krouse'  attempted  to  infect  rabbits,  cats,  pigeons,  and  mice.  Wert- 
heim^  claims  to  have  produced  a  mild  peritonitis  in  mice,  rabbits,  and 
rats  by  inoculation  of  gonococci.  Finger  also  has  reported  having 
produced  an  inflammation  of  the  knee-joint  of  a  dog  from  a  pure  cul- 
ture of  gonococcus  grown  on  serum-agar.  These  results  were  probably 
produced  by  toxins  which  are  present  in  both  the  living  and  the  dead 
gonococci.  Indeed,  it  is  to  these  substances  that  the  discharge  of 
gonorrhea  is  attributed. 

Toxins. — The  gonococcus  develops  a  gonotoxin.  This  is  present  in 
the  cells  after  heating  and  contact  with  alcohol.  The  production  of  a 
toxin  has  been  demonstrated  by  Wassermann,^  de  Christmas,^  and 
others.  There  is  still  some  doubt  as  to  the  exact  nature  of  the  toxin, 
some  believing  that  it  is  set  free  only  by  the  disintegration  of  the  gono- 
cocci,— in  other  words,  an  endotoxin, — whereas  other  authorities  con- 
sider it  a  product  of  bacterial  metabolism. 

Rogers  and  Torrey^  state  that  the  repeated  injection  of  free  gono- 
toxin in  culture-media  had  a  disastrous  effect  on  rabbits  that  were 
used  in  the  production  of  antigonococcic  serum.  Although  the  ani- 
mals suffered  Uttle  from  the  first  5  or  6  inoculations,  they  soon  after 
reached  a  condition  of  hypersensitiveness  to  the  toxin  and  finally 
succumbed  to  a  dose  that  would  never  have  proved  fatal  to  a  normal 
animal.  This  seems  to  indicate,  as  Wassermann^  and  others  have 
pointed  out,  that  the  toxin  in  culture-media  is  not  produced  in  diffus- 
ible form  by  the  living  gonococcus  cells,  but  is  an  endotoxin  derived 
from  the  dead  and  disintegrated  gonococci. 

Injections  of  small  quantities  of  gonotoxin  in  rabbits  or  mice  pro- 
duce no  results.  In  large  quantities  fever,  infiltration,  and  sometimes 
necrosis  are  produced.  If  the  injections  are  persisted  in  or  the  doses 
are  very  large,  loss  of  weight  and,  finally,  death  occur.  Inoculated 
into  the  urethra  of  man,  a  transient  urethritis  is  produced.  The  toxin 
injected  into  the  cellular  tissue  of  man  produces  a  painful  celluhtis 

'  Wildbolz,  H.:  Zent.  f.  Bakteriologie,  vol.  xxxi,  Xo.  4. 
^  LofflcT  and  Leistikow:  Charite-Annalen,  7.  Jahrg. 
'  lu-ouse:  Cent.  f.  AugenJieilk.,  1882,  p.  134. 
*  Werlheim:  Arch.  f.  Dermat.  u.  Sj-ph.,  1899,  vol.  xli,  No.  1. 

^Wassermann:  Zeit.  f.  Hyg.  u.  Infektions-foankh.,  vol.  xxvii,  Xo.  2:  also  Berlin, 
klin.  W  och.,  1897,  No.  32. 

«  de  Christmas:  Ann.  Institut  Pasteur,  1897;  also  ibid.,  1900,  vol.  xlv,  p.  331. 
■  Rogers,  J.,  and  Torrey,  J.  C:  Jour.  Amer.  Med.  Assoc,  September  14,  1907. 
»  Wa-sscnnami :    Quoted  by  Rogers  and  Torrey:  Loc.  cii. 


BACTERIOLOGY    OF   THE    GONOCOCCUS  /O 

which  lasts  several  da3's.     Repeated  injections  probably  give  no  im- 
munitj-. 

The  filtrate  prepared  from  recent  cultures  of  gonococci  contains 
little  or  no  toxin. 

The  exact  part  which  the  toxin  plays  in  the  production  of  infection 
is  still  undetermined.  It  is  not  known  if  the  poison  is  capable  alone 
of  producing  metastases,  or  if  any  parts  of  the  body  are  especially 
susceptible  to  it,  if  it  can  diffuse  itself  throughout  the  body,  or  if  its 
action  is  purelj'  local  and  intimately  associated  with  the  presence  of 
the  gonococcus  itself. 

Nikolaysen^  claims  to  have  isolated  the  toxin  by  means  of  distilled 
water  or  sodium  hydroxid  from  the  bacterial  bodies.  This  toxin  is 
found  to  remain  active  after  complete  drying  or  after  exposure  to  120° 
C.  of  heat.  Nikolaysen  found  the  toxin  quite  as  poisonous  to  animals 
as  was  a  pure  culture  of  living  gonococci,  0.01  gram  killing  a  white 
mouse.  Specific  injury  to  the  nervous  system  by  the  injection  of  a 
gonococcal  toxin  has  been  described  by  Moltschanoff.- 

Immunity. — If  man  possesses  any  immunity  at  all,  it  is  extremely 
transient — so  short  lived,  in  fact,  as. to  be  of  no  practical  value.  On 
account  of  the  chronicitj'  and  frequent  latency  of  gonorrhea,  this  point 
is  difficult  to  determine  positively.  Animals  may  be  jiartially  im- 
munized to  the  toxin,  in  which  case  their  blood  is  said  to  possess  slight 
antitoxic  and  bactericidal  properties.  Torrej'^  has  produced  immunity 
in  guinea-pigs. 

Agglutination. — This  test  is  of  no  great  practical  diagnostic  value. 
The  gonococci,  Uke  certain  other  pathogenic  cocci,  possess  many 
strains  that  differ  markedly  in  their  specific  character  and  have  but 
few  common  agglutinins. 

Bacteriologic  Properties  of  Micrococci  Likely  to  be  Confused  with 
the  Gonococcus.  -Under  this  heading  may  he  placed  a  gi'ouj)  of  micro- 
organisms known  as  tlie  pscudogonococci.  This  name  has  been  ap- 
plied to  them  In'  ]Mannaberg,  Lustgarten,  andBunnn.''  These  organ- 
isms are  morphologically  very  similar  to  the  gonococcus,  but  may  be 
distinguished  from  the  latter  by  their  method  of  growth  and  staining 
properties.  The  identity  of  this  group  of  microorganisms  as  special 
germs  has  been  established.  They  are  usually  regarded  as  varieties 
of  skin  or  air  cocci  that  have  accidentally  obtained  access  to  the  genital 
tract. 

Micrococcus  Cilreus  Conglomerala  (Bumm*). — This  microorganism 
'  Nikolaysen:  Cent.  f.  Biikt.,  l.S'J7;  also  Fort.  ti.  Med.,  1S'.)7,  vol.  xxi. 
2  iMoltschanolT:  Munch,  nicd.  Woch.,  1899. 
'  Toiri-y,  J.  C:  Med.  Kasearch,  1908,  p.  ;J47. 
*  Huintn:  Vfit's  Handb.  der  Gyn.,  vol.  ii. 


76  GONORRHEA   IN   WOMEN 

is  morphologically  similar  to  the  gonococcus.  It  is  Gram-positive, 
easily  cultivated,  and  forms  colonies  that  grow  on  and  dissolve  gela- 
tin. On  the  surface  of  the  latter  the  micrococcus  grows  rapidly  and 
forms  a  moist,  shining,  unwrinkled  growth.  The  organism  is  not 
pathogenic.     It  is  found  in  the  air  and  in  gonorrheal  pus. 

Diplococcus  Albicans  A^yiplus  (Bwnm'^). — This  diplococcus  is  found 
in  the  normal  lochia,  and  is  considerably  larger  than  the  gonococcus. 
It  Uquefies  gelatin,  and  on  this  medium  produces  a  grayish-white 
colony.  Its  growth  is  moderately  rapid.  In  staining  reaction  the 
organism  is  Gram-positive. 

Diplococcus  Albicans  Tardissimus  (Bumni). — This  micrococcus  is 
Gram-positive,  and  has  been  found  in  urethral  pus.  On  the  usual 
culture-media  it  grows  slowly  at  ordinary  temperatures,  but  more 
rapidly  at  37°  C.  It  does  not  hquefy  gelatin.  Colonies  appear  as 
small  white  excrescences  that,  under  the  low  power,  are  opaque,  semi- 
translucent,  and  brown.  Agar  stroke  cultures  present  a  grayish-white 
growth.     In  old  colonies  the  surface  is  wrinkled. 

Micrococcus  Subflavus  (Bumm). — Is  Gram-positive  and  has  been 
found  in  the  lochia  and  urethra  of  healthy  women.  This  micrococcus 
grows  slowly  on  all  media.  On  gelatin  it  produces  a  moist,  yellowish- 
brown  colony  that  liquefies  the  medium  slowly.  On  potatoes  the 
Micrococcus  subflavus  produces,  at  the  end  of  two  or  three  weeks, 
crescent-shaped  colonies  that  have  a  wrinkled-skin-like  surface  and  are 
light  brown  in  color.  Pathogenesis:  Has  no  action  on  mucous  mem- 
branes, but  wheh  injected  into  cellular  tissue  produces  an  abscess  in 
the  pus  of  which  large  numbers  of  diplococci  may  be  found.  Wormser- 
states  that  the  Micrococcus  fallax  may  be  mistaken  for  the  gonococcus, 
but  may  be  distinguished  from  the  latter  by  culture  methods.  This 
author  states  that  the  Micrococcus  fallax  does  not  react  regularly 
with  Gram's  stain,  but  is  usually  negative.  The  coccus  is  easily  de- 
stroyed by  weak  alkaline  solutions,  but  is  extremely  resistant  to 
solutions  of  potassium  permanganate.  The  gonococci  may  be  dis- 
tinguished from  the  pseudogonococci  by  the  fact  that — (a)  The  former 
can  usually  be  found  intracellularly.  (b)  They  are  Gram-negative, 
(c)  They  do  not  grow  on  gelatin  (at  least  in  the  first  generation,  and 
only  very  exceptionally  at  any  time),  (c)  The  micrococci  just  men- 
tioned are  all  easily  cultivated,  whereas  the  gonococci  grow  only  spar- 
ingly and  with  difficulty,  and  only  upon  special  media.  The  fermenta- 
tion test  is  here  of  value.  This  depends  upon  the  acid  reaction,  which 
is  produced  by  the  growth  of  the  organism  with  various  sugars.     The 

'  Bumm,  E. :  Der  Mikro-organismus  gonorrlioisfheii  Schleimhaut-ErkMnkungen,  Wies- 
badon,  1SS5. 

-  WormscT,  L.:  Annal.  dcs  Maladies  Gen.-rrin.,  Mart-h  20,  UllO. 


BACTERIOLOGY    OF   THE    GONOCOCCUS 


77 


organism  is  grown  in  litmus  broth  and  ascitic  fluid  containing  glucose, 
galactose,  maltose,  or  saccharose.  According  to  Mayou,^  the  follow- 
ing reaction  is  obtained:  The  gonococcus  gives  an  acid  reaction  with 
glucose  and  galactose.  Meningococcus  gives  an  acid  reaction  with 
glucose,  but  not  with  galactose.  ]M.  catarrhalis  gives  no  reaction 
with  either. 

Elser  and  Huntoon-  present  the  following  table,  showing  the  value  of 
sugar  fermentation  in  the  identification  of  the  aforementioned  bacteria : 


Strains  Tested 


200 


Meningococcus 

Pseudomeningococcus 

Gonococcus 

Micrococcus  catarrhalis 

Micrococcus  pharyngeus  siccus 2 

Chromogenic  Group  I 28 

Chromogenic  Group  II 11 

Chromogenic  Group  III I       9 

.laeger  moningococcus  (  Krai) 1 

Diplococcus  cra-ssus  (.Krai) 1 


Mai^ 

Levtj- 

T08E 

LOBE 

+ 

0 

+ 

0 

0 

0      , 

0 

0      ' 

+ 

+ 

+ 

+ 

+ 

+ 

+ 

0 

+ 

+ 

+ 

+ 

Meningococcus  or  Diplococcus  Intracellular  is  Meningilidis. — This 
micrococcus  is  Gram-negative.  '  It  gives  luxuriant  and  rapid  growth 
on  a  wide  variety  of  media.  In  serum  bouillon  it  produces  a  turbidity 
that  is  later  deposited  at  the  bottom  of  the  test-tube.  The  young 
colonies  have  delicate,  almost  invisible  margins,  the  centers  of  which 
later  become  grayish-white.  The  meningococcus  is  occasionally 
present  in  the  female  genital  tract.  It  may  produce  oi)hthalmia,  and 
has  been  found  in  the  blood  and  spinal  fluid.  The  enzymotic  proper- 
ties are  irregular  and  similar  to  those  of  the  gonococcus.  Both  or- 
ganisms act  in  much  the  same  manner  when  kept  in  the  same  media  and 
environment,  but  the  meningococcus  is  the  stronger  grower  (Flexner'). 
This  is  especially  so  of  cultures  two  or  more  days  old.  The  meningo- 
coccus  is  frequently  found  in  or  on  the  cells. 

Pollock  and  Harri.son''  sum  up  the  differences  between  the  gonococ- 
cus and  the  meningococcus  when  grown  on  artificial  media  by  stating 
that,  in  general,  the  meningococcus  is  less  sensitive  to  changes  in  tem- 
perature and  reaction  of  the  medium,  grows  more  rapidly  on  scrum 
agar,  and  its  colonies  are  more  opaque  than  those  of  the  gonococcus, 
and  that  it  can  generally  be  cultivated  on  plain  nutrient  agar.     The 

'  Mayou:  The  Practitioner,  London,  1908,  pp.  125,  200,  and  3.54. 
'  Elscr  and  Huntoon:   Quoted  by  P.  H.  Hiss  and  H.  Zins.ser;   A  Text-book  of  Bac- 
teriology, 1910,  p.  387. 

'  Flexncr,  S. ;  .lour.  Expcr.  Med.,  March,  1907. 

'  Pollock,  C.  E.,  and  Harrison,  L.  W.:  Gonococcal  Infections,  London,  1912,  p.  20. 


78  GONORRHEA   IN   WOMEN 

meningococcus  degenerates  even  more  rapidly  than  the  gonococcus. 
The  meningococcus  forms  acid  with  maltose  and  dextrose,  while  the 
gonococcus  ferments  dextrose  only.  Martin^  states  that  on  his 
medium  the  edges  of  the  colonies  of  the  meningococcus  are  more  trans- 
parent than  are  the  colonies  of  the  gonococcus. 

Micrococcus  Catarrhalis. — This  organism  was  first  described  by 
R.  Pfeiffer-  in  1896,  and  in  the  same  year  is  referred  to  by  Frosch  and 
Kolle.  Later  Ghon,  H.  Pfeiffer,  and  SederP  and  von  Lingelsheim^ 
carefully  studied  this  microorganism. 

Its  habitat  is  the  respiratory  tract,  especially  the  nose,  mouth,  and 
throat.  It  has  also  been  found  in  the  eyes.  Gurd^  and  others  have 
found  this  micrococcus  present  in  the  inflamed  genital  tract  of  men  and 
women.  According  to  Gurd,  the  micrococci  described  by  von  Lingels- 
heim,^  and  called  by  him  Micrococcus  pharyngeus  sicca,  M.  pharyngeus 
cinereus,  Diplococcus  pharyngeus  flavus  I,  D.  pharyngeus  flavus 
II,  and  D.  pharyngeus  flavus  III,  differ  from  the  Micrococcus  catarrh- 
aUs  and  one  another  only  in  the  amount  of  pigment  that  they  develop, 
and  which  gives  them  their  yellow  color.  In  cUfferentiating  these 
micrococci  from  the  gonococci  Gurd  lays  especial  stress  on  the  fact 
that  the  latter  produce  a  dehcate  growth,  which  is  comparatively 
restricted  to  serum  media  of  a  particular  reaction.  This  microorgan- 
ism is  Gram-negative,  and  grows  readily  on  gelatin  at  room  tempera- 
ture. It  is  an  active  grower  on  most  media.  In  serum  bouillon  it 
forms  a  scum,  and  later  deposits,  but  does  not  produce  turbidity. 
The  colonies  have  an  opaque,  white,  shining  appearance.  Park  and 
Williams^  state  that  the  Micrococcus  catarrhaUs  does  not  liquefy 
gelatin,  and  that  on  bouillon  it  produces  a  cloudy  growth,  with,  often, 
the  development  of  a  pedicle.  Milk  is  not  coagulated  by  this  micro- 
organism, but  dextrose  serum  may  be.  As  the  colonies  develop  the 
centers  become  elevated  and  the  edges  crenated.  The  surface 
colonies  of  gonococci  are  grayish,  bluish,  or  whitish,  and  are  radially 
plicated,  concentrically  striated,  have  granular  centers,  scalloped  mar- 
gins, and  present  a  poor  growth  (sUght  granular  deposits)  in  serum 
bouillon. 

Libman  and  Cellei-^  found  that  the  Micrococcus  catarrhalis  was 

'  Martin,  W.  B.:   Jour.  Path,  and  Bact.,  July,  1910. 

=  Pfeiffer,  R.:   Die  Mikroorg.,  tiiird  edition,  1896. 

»  Ghon,  Pfeiffer,  and  Sederl:  Zeit.  f.  klin.  Med.,  1902,  vol.  xl. 

*  von  Lingebheim :   Klin.  Jahrbuch,  1906,  vol.  xv,  2. 

'  Gurd:  Jour.  Med.  Research,  1910,  vol.  xxiii;  n.  s.,  vol.  xviii,  p.  154. 

'  von  Lingelsheim:  Loc.  cit. 

'  Park  and  Williams:  Pathogenic  Bacteria  and  Protozoa,  New  York,  1908. 

«  Libman  and  Celler:  Reports  of  Mt.  Sinai  Hospital,  1903. 


BACTERIOLOGY    OF    THE    GONOCOCCUS  79 

more  nearly  oval  in  form  than  the  gonococcus,  and  slightly  larger. 
Aj'res^  believes  that  this  organism  is  responsible  for  a  definite  propor- 
tion of  cases  of  urethritis;  that  these  infections  are  characterized 
clinically  by  the  mildness  of  their  onset,  and  are  often  mistaken  for 
gonorrhea.  According  to  Ayres,-  such  cases  should  not  be  treated 
locally,  as  they  get  well  without  treatment,  whereas  the  apphcation  of 
silver  preparations  may  cause  them  to  continue  indefinitely.  The  same 
writer  reports  cases  of  pelvic  inflammatory  diseases  due  to  the  Micro- 
coccus catarrhahs,  one  being  a  mixed  infection  with  the  staphylococcus, 
and  the  other  being  due  probably  to  the  Micrococcus  catarrhahs  alone. 
Hiss  and  Zinsser^  and  Libman  and  Celler^  state  that  the  Micrococcus 
catarrhalis  is  of  slight  pathogenicity. 

In  1906  von  Lingelsheim^  described  the  Diplococcus  mucosa.  The 
colony  formation  is  similar  to  the  meningococcus,  but  is  somewhat 
more  mucoid  in  character.  This  microorganism  can  easily  be  distin- 
guished from  the  former  and  from  the  gonococcus  by  capsular  stains, 
as  by  them  it  will  be  found  to  possess  a  cUstinct  capsule. 

Bacteriologic  Diagnosis  of  Gonorrhea. — In  the  great  majority  of 
acute  cases  gonorrhea  may,  to  all  intents  and  purposes,  be  diagnosed 
positiveh'  by  the  morphology  and  staining  reaction  of  the  gonococcus 
found  in  film  preparations,  and  this  is  especially  true  in  the  male.  No 
other  micrococcus  possessing  the  same  appearance  and  staining  prop- 
erties, and  capable  of  producing  the  clinical  symptoms  of  an  acute 
severe  urethritis,  has  ever  been  demonstrated  in  cultures  from  this 
region.  In  chronic  cases  staining  methods  offer  a  less  certain  means  of 
diagnosis,  not  only  because  the  gonococci  are  present  in  reduced  num- 
bers, but  particularly  on  account  of  the  fact  that  in  these  cases  the 
specific  micrococcus  is  often  atypical  in  size,  shape,  and  staining  re- 
action. Finger,  Schaeffer  and  Steinschneider,^  and  Galewski  found 
that  a  Gram-negative  diplococcus  which  was  not  the  gonococcus  oc- 
curred in  only  from  4.(j  per  cent,  to  4.8  per  cent,  of  cases  in  a  large  series. 
This  shows  that  over  95  per  cent,  of  cases  can  be  correctly  diagnosed 
by  the  Gram  method  of  staining.  In  all  cases  of  doubt — and  this 
refers  particularly  to  old  chronic  or  latent  cases,  where  the  patients 
desire  to  marry,  and  in  everj^  case  in  which  the  medicolegal  aspect  is 
likely  to  be  involved,  or  where  an  absolute  diagnosis  is  desired,  as  in  the 
case  of  rare  lesions — cultures  should  be  made.     Because  of  the  difficulty 

'  Ayres,  W. :  Amer.  Jour.  Surg.,  New  York,  March,  1912,  p.  101. 

'Ayres:  Loc.  cU. 

'  Hiss,  P.  H.,  and  Ziasscr,  H.:  A  Text-book  of  Bacteriology,  1910. 

*  Libman  and  Celler:  Loc.  cil. 

'  von  Lingelslu^im:  Klin.  Jahrb.,  190C,  vol.  xv. 

'  ■Selincffcr  and  Stoin.sehneider:   Kong.  Dcut.  Derniat.  Cicseil.,  Breslau,  1894. 


80  GONORRHEA    IN    WOMEN 

in  cultivating  the  gonococcus  on  artificial  soil  the  cultures  should  be 
undertaken  only  by  an  experienced  bacteriologist.  If  negative  re- 
sults are  obtained,  either  by  the  staining  or  by  the  culture  method, 
repeated  examination  should  be  made  under  the  most  favorable  cir- 
cumstances. 

IMcFarland^  summarizes  the  characteristics  of  the  gonococcus 
as  follows:  Non-sporogenous,  non-liquefying,  non-chromogenic,  non- 
flagellate,  aerobic,  strictly  parasitic,  not  stained  by  Gram's  method, 
requiring  special  culture-media,  and  pathogenic  only  to  man.  In- 
deed, Wertheim-  and  Schanz^  state  that  negative  culture  tests  must  be 
always  viewed  with  suspicion  on  account  of  the  capriciousness  with 
which  many  stains  of  gonococci  grow  even  upon  the  most  favorable 
artificial  media.  Of  late  years,  however,  the  routine  cultivation  of  the 
gonococcus  on  artificial  media  has  been  carried  out  with  marked  suc- 
cess. Thus  Butler  and  Long''  state  that  they  experienced  no  cUfnculty 
in  cultivating  this  organism  from  a  large  series  of  cases,  and  while  it 
is  undoubtedly  true  that  the  gonococcus  requires  a  special  medium  for 
its  development  and  care  must  be  exercised  regarding  the  temperature 
at  which  it  is  incubated,  it  seems  probable  that  in  the  past  the  dif- 
ficulty in  cultivating  the  organism  has  been  somewhat  overestimated. 
A  point  of  the  utmost  importance  in  securing  material  for  cultures  is 
that,  when  possible,  the  material  be  obtained  by  curetage  of  the  dis- 
eased area.  Thus  in  arthritis  the  joint  fluid,  be  it  serum  or  pus,  will 
be  negative  in  a  much  larger  proportion  of  cases  than  will  be  particles 
of  the  granulation  tissue  that  can  be  secured  by  scraping  the  cavity. 
Gurd^  has  emphasized  this  point  regarding  cultures  from  pus- tubes, 
and  states  that  the  negative  results  often  obtained  are  due  to  this  fact. 
It  is  well  known  that  prolonged  encapsulation  tends  to  destroy  the 
vitality  of  the  gonococcus,  which  will  often  be  dead  or  of  greatly  les- 
sened virulence  in  pus,  while  active  organisms  may  be  found  in  the 
walls  of  the  abscess. 


Diagnosis  op  Gonorrhea  by  the  Complement-fixation  Test 
In  1906  Miiller  and  Oppenheimer"^  suggested  applying  the  comple- 
ment-fixation test  as  a  means  of  diagnosis  in  cases  of  gonorrhea,  and 

'  McFarland,  J.:   A  Text-book  upon  Tathogenic  Bacteria  and  Protozoa,  Philadelphia 
and  London,  1912. 

'  Wertheim:  Arch.  f.  Dermat.  u.  Syph.,  1899,  vol.  xli,  No.  1. 

^  Schanz:  Deut.  med.  Wochonschr.,  Leipzig  and  Beriin,  1004,  vol.  xxx,  p.  350. 

'  Butler,  W.  J.,  and  Long,  J.  P. :  111.  Med.  Jour.,  1908,  vol.  xiii,  p.  538. 

'  Gurd:  Jour.  Med.  Research,  1910,  vol.  xxiii;  new  series,  vol.  xviii,  p.  15-4. 

"  Miiller  and  Oppcnhoimer:  Wien.  klin.  Woch.,  1906,  No.  19,  p.  894. 


1 


BACTERIOLOGY   OF    THE    GONOCOCCUS  81 

reported  one  case  in  \\-hich  the  method  had  been  successful.     Further 
investigations  on  this  subject  have  been  published  by  Bruck,i  Meak- 
insr    Vanned,'    Wollstein/    Torrey/    Watabiki/    Kohler/  'Eising,^ 
Gradwohl,^  and  Schwartz  and  McNeil.i"     The  last-mentioned  investi- 
gators have  applied  the  complement-fixation  test  to  a  series  of  324 
human  sera.     These  sera  were  taken  from  persons   of  both  sexes 
having  acute  or  chronic  gonorrheal  infection;    from  others  having  no 
history  of  chnical  manifestations  of  gonorrhea,   and   from  patients 
suffering  from  various  diseases  other  than  gonorrhea.     Schwartz  and 
McXeil  used  many  different  strains  of  gonococci  in  the  preparation 
of  the  antigen;    in  other  words,  a  polyvalent  antigen.     In  the  great 
majority  of  the  cases  tested,  clinically  12  strains  of  gonococci  were 
used  m  the  preparation  of  the  antigen.     This  antigen  seemed  to  give 
more  uniformly  accurate  results  than  some  prepared  from  only  6 
strains.     In   their  work  they  used  both  antisheep  and  antihuman 
hemolytic   sera   and  followed   the  technic   laid    down   in    the  well- 
known  Wa.ssermann  test  for  .syphihs,  and  in  Noguchi's  modification 
of  the  Wassermann  test.     Among  29  women  in  whom  gonorrhea  was 
defimtely  present  or  suspected,  23  were  positive  and  6  were  negative. 
Among  a  miscellaneous  series  of  20  cases,  in  none  of  which  a  history  or 
phyi^ical  signs  of  gonorrhea  were 'present,  10  were  positive  and  30 
negative.     In  a  series  of  pregnant  women  the  following  results  were 
obtained :  35  cases  showed  no  .'^igns  of  gonorrhea ;   14  were  positive  and 
21  negative.     One  pregnant  goiiorrheic  was  positive  and  one  pregnant 
patient  with  a  marked  antepartum  discharge  in  which  no  gonococci 
were  found  was  negative.     The  table  on  p.  82  is  a  summary  of  the 
results  obtained  by  Schwartz  and  McNeil. 

In  a  later  communication  Schwartz  and  McNeil"  confirm  their 
previous  conclusions.  They  state  that  a  positive  reaction  can  rarely 
be  obtained  before  the  fourth  week  of  the  disease,  and  that  the  reaction 

'  Bruck,  C:   D.-uis.-l.c  „i(d.  Woch..  l<)(Hi,  xxxii.  p.  VMiS. 
'Mciikins:   .Inhn.s  Hopkins  Ho.-ip.  Bull.,  1007    \(,    Is    p     >-,-, 

•  Woll.stcin:  Jour.  Exper.  Mod.,  1!)07,  No.  9,  p.  588. 

'  Torrcy,  J.  C:  .Jour.  Mod.  Kosoarch,  1907,  No.  17,  p.  223. 

'Hutubiki,  T.:  Jour.  Infoc.  Di.s.,  lilio,  \o.  7,  p.  15<). 
FixJion  Tos;  l^;V,)\''''\'^li"v)^'™;''''''«']'-'  •^''vw.'.l'.'r  '•),  191 1 ;  \aluo  of  Iho  Con.plonunt- 
2^19  "nSS)'  T  'V'i':''"''  ;""'  '^'';'."'"  •^"""■■^'  •'"'"•  A.nor.Mod.  Asso,.,  Mur.li 

Wi  !{^nI:^';iHV  p''l:S     ^"■■"'''■■■"•■"-"'-'"""   '<-'■'-■  Ai.s.raot  and  Disoussion 

"  Kising,  E.  11.:  Mod.  Kocord,  .Juiio  1,  1012. 

^  (iradwohl,  U.  B.  H.:  Amcr.  .Jour.  Domiat.,  1912,  vol.  xvi,  No.  6,  p  294 
p.69:j'!^'''"''"'''''  "•  ■'■'  ""''  ^''■^'■"'  '^•-  '^""''-  •'"""••  ^'<-''-  ««'•-  101 1.  new  series,  vol.  oxli, 
'■  Sduvuru,  H.  .1.,  a,.d  .\I,\,.il,  A.:   Anu-r.  .lour.  Mod.  .Soi.,  I>oo>nl.or,  1012,  p.  S1.9. 


82 


GONORRHEA   IN   WOMEN 


persists  for  seven  or  eight  weeks  after  cure;   that  the  reaction  is  often 
absent  if  only  the  anterior  urethra  is  involved. 




. 

Positive            I 

Negative 

Total 

Number 

Clinical  Diagnosis 

OF  Cases  ; 

Number 

Per  Cent. 

Number 

Per  Cent. 

1.  Acute  gonorrheal  urethritis: 

(o)  Duration    three   days    to   three 

5 
1 

0 

1 

0 
100 

5 
0 

100 

(bj   Duration  not  stated 

0 

2.  Acute  urethritis: 

Oonococcus  not  found 

1 

0 

0 

1 

100 

3.  Chronic  uiethritis  (gonorrheal;: 

(fi^  Gonococcus  present 

4 

4 

100 

0 

0 

fj^\  Oonococcus  not  founo 

36 

27 

80 

9 

20 

(c)   No  examination  made  for  gono- 

cocci,  but  serum  taken  from  cases 

at  stage  when  gonococci  are  usually 
absent 

8 

7 

90 

1 

10 

4.  Chronic  urethritis: 

Gonorrhea  doubtful 

4 

1 

25 

3 

75 

5.  Chronic  prostatitis: 

8 

32 

(a.)  Gonorrheal  history 

25 

17 

68 

(b)  Gonorrheal  history  doubtful  ... 

2 

1     ■ 

50 

1 

50 

6.  SteriUty,  gonorrheal  history 

3 

1 

33 

2 

66 

7.  Epididymitis: 

(a)  Gonorrheal  history 

3 

2 

66 

1 

33 

(b)  Gonorrhea  denied 

4 

1 

25 

3 

75 

8.  Verumontanum  cases: 

(d)  Gonorrheal  history 

17 

11 

64 

6 

35 

(b)   Gonorrhea  denied 

6 

2 

33 

4 

66 

9.  Miscellaneous  cases  with  no  sign  or 

history  of  gonorrhea 

20 

0 

0 

20 

100 

10.  Gonorrhea  in.male  cUnieally  cured  .     .  . 

51 

22 

43 

29 

57 

11.  Cases  treated  with  bacterins 

7 

7 

100 

0 

0 

12.  Joint  affections: 

(a)  Gonorrheal  arthritis 

14 

14 

100 

0 

0 

(b)  Gonorrheal  arthritis  questionable 

7 

4 

57 

3 

43 

(c)  Other  ioint  affections 

9 

1 

11 

8 

89 

13.  Pregnancy   cases  taken   from   public 

maternity  hospitals 

38 

15 

39 

23 

61 

14.  Gynecologic  cases: 

1 

1 

(a)  Gonorrhea  definitely  present  or 

suspected  

29 

23 

79 

6 

21 

(6)   Cases  with  no  signs  or  history  of 

gonorrhea 

30 

10 

33 

20 

1       66 

'' 

It  would  seem,  from  the  foregoing,  that  the  complement-fixatio 
test  should  be  a  decided  adjunct  in  the  field  of  cUnical  pathology  as 
an  aid  in  the  diagnosis  of  gonorrhea.  Swinburne^  and  Keyes^  re 
gard  this  test  very  highly.  Schmidt^  presents  the  following  results 
which  he  has  obtained  in  77  cases : 

1  Swinburne,  G.  K.:  Trans.  Amer.  Urol.  Assoc.,  1912,  vol.  v,  p.  21. 
^Keyes,  Jr.,  E.  L.:  Trans.  Amer.  Urol.  Assoc,  1912,  vol.  v,  p.  40. 
'Schmidt,  L.  E.:  Ibid.,  p.  30. 


J 


BACTERIOLOGY    OF   THE    GONOCOCCUS 


83 


Clinical  Diaonosis 


Acute  gonorrhea 14 

Chronic  gonorrhea 32 

Epididymitis 11 

Artliritis :  i  5 

Gonorrheal  history  of  from  one  to  ten  years  I  27 

Gonorrheal  history  negative i  11 


Number     Per  Cent.     Number      Per  Cent. 


91 
54 
55 
60 
92 
100 


It  seems  to  be  of  especial  value  in  the  diagnosis  of  joint  condi- 
tions. Schmidt,'  after  having  tested  the  complement-fixation  test  in 
103  cases,  states  that  the  results  indicate  that  a  negative  test  in 
a  patient  is  good  evidence  that  the  disease  is  cured.  Gardner  and 
Clowes-  report  that  in  a  series  of  106  gonorrheal  cases  23  showed  a 
three-plus  reaction,  15  a  two-plus,  23  a  one-plus,  whereas  37  were 
negative.  Of  the  23  cases  showing  a  three-plus  reaction,  20  were 
examined,  in  18  of  which  an  intracellular  diplococcus  was  found.  Of 
the  15  cases  giving  a  two-plus  reaction,  13  were  examined,  in  9  of 
which  an  intracellular  diplococcus  was  demonstrated.  Of  the  23 
cases  showing  a  one-plus  reaction,  17  were  examined,  and  in  11  an 
intracellular  diplococcus  discovered.  These  authors  believe  that  the 
three-plus  and  two-plus  reactions  are  fairly  diagnostic  of  the  presence 
of  gonorrhea,  while  a  one-plus  reaction,  without  being  confirmed  by 
clinical  data,  should  not  be  regarded  more  seriously  than  should  a  one- 
plus  Wassermann  reaction.  Gradwohl,^  after  an  experience  with  50 
cases  tested  with  the  complement-fixation  test,  states  that  this  test 
does  not  appear  to  have  nearly  so  many  hmitations  as  does  the  Was- 
sermann test  for  syphilis.  It  is  a  genuine  antigen-antibodj^  test. 
A  gonorrheal  fixation  test  once  positive  and  later  negative  is  of  great 
value  in  estimating  a  cure.  In  persons  recently  infected  the  test  is 
apt  to  be  negative.  Schwartz*  states  that  a  positive  reaction  should 
not  be  expected  earlier  than  about  the  beginning  of  the  fourth  week 
from  the  onset  of  the  infection.  Irons"  states  that  occasionally  in 
adults,  and  more  frequently  in  children,  a  fairly  positive  reaction  occurs 
in  persons  who  have  never  had  gonorrhea.  It  would  seem  that  the 
test  should  be  especially  valuable  in  the  case  of  women  in  whom,  dur- 
ing the  chronic  stage,  gonococci  are  very  difficult  to  demonstrate. 

To  l)e  of  any  value  whatever,  the  complement-fixation  test  must 
be  carried  out  by  a  siiilled  bacteriologist,  and  every  technical  pre- 

'  Schmidt,  L.  E.:  Jour.  Amer.  Med.  Assoc.  April  27,  1912,  p.  1307. 

'  Gardner  and  Clowes;  Jour.  .^mcr.  Med.  Assoc.,  April  27,  1912,  p.  1307. 

•  Gradwohl,  U.  B.  H.:  .\mcr.  Jour.  Denniit.,  June,  1912. 

*  Schwartz,  H.  J.:  Amer.  Jour.  Med.  Sci.,  Septcmlier,  1912,  vol.  cxliv,  No.  3. 
'  Irons,  E.  E.:  Jour.  Infec.  Disea.ses,  July,  1912,  p.  77. 


g4  GONORRHEA    IN    WOMEN 

caution  observed.  A  positive  reaction  indicates  a  focus  of  gonorrhea 
in  some  part  of  the  body,  but  a  negative  test  does  not  necessarily 
exclude  the  disease.  It  is  at  once  apparent  that  acute  gonorrhea  will 
not  show  a  positive  result  until  sufficient  time  has  elapsed  to  pernut 
the  absorption  of  enough  toxin  to  cause  a  systemic  response  to  in- 
vasion, as  shown  by  the  antibodies  of  various  types  in  the  serum. 
The  test  is  usually  negative  until  about  the  tWrd  or  fourth  week.  In 
subacute  or  chronic  gonorrheas  the  chances  of  a  positive  result  are  greatly 
hicreased,  the  percentage  of  positive  results  being  about  as  high  as  in 
similar  tests  for  syphilis.  In  cases  of  gonorrhea  that  are  supposedly 
cured,  a  positive  reaction  would  indicate  a  focus  of  infection  somewhere 
in  the  system  of  such  virulence  that  transmission  of  the  disease  would 
be  more  than  likely  to  follow,  provided  the  focus  was  so  situated  that 
transmission  was  possible.  But  it  must  be  remembered  that  gonor- 
rheal antibodies  persist  for  some  time  after  the  disappearance  or  de- 
struction of  the  invading  gonococci. 

A  negative  result  cannot  justify  in  any  way  the  exclusion  of  gonor- 
rhea, as  in  not  a  few  cases  that  have  been  bacteriologically  proved  to  be 
gonorrhea  a  negative  reaction  was  obtained.  Gardner  and  Clowes^  state, 
however,  that  in  the  185  tests  made  by  them  a  positive  reaction  was  never 
obtained  in  any  but  a  gonorrhoic.  Schwartz, =  after  reviewing  addi- 
tional cases  than  those  previously  recorded,  concluded  that  the  test  is 
of  great  practical  value.  O'Neil,'  after  a  series  of  256  tests,  is  of  a 
similar  opinion. 

More  research  will  be  required  before  the  exact  value  and  scope  of 
the  complement-fixation  test  can  be  definitely  determined. 

Diagnostic  Vaccination.— In  1908  Irons^  noted  that  subcutaneous  in- 
oculation of  dead  gonococci  in  persons  suffering  from  gonorrhea  fre- 
quently was  followed  in  from  twelve  to  twenty-four  hours  by  local  and 
general  reaction.  This  reaction  consists  of  an  area  of  redness,  swelling, 
and  tenderness  at  the  site  of  the  inoculation,  often  an  increased  pain  and 
tenderness  in  affected  joints  and  other  localizations,  together  with  symp- 
toms of  malaise  and  sometimes  increase  in  fever  and  leukocytosis.  These 
phenomena  resemble  those  seen  in  the  tuberculin  reaction,  and  are  of 
value  in  the  diagnosis  of  obscure  cases  in  which  gonococcal  infection 
is  suspected.  This  reaction  has  been  noted  by  many  investigators. 
Reiter^  observed  the  reaction  in  women  suffering  from  pelvic  inflam- 
matory diseases  of  gonococcal  origin.     Irons"  states  that  in  positive 

'  Gardner,  J.  A.,  and  Clowes,  C.  H.  A.:  New  York  Med.  Jour.,  October,  1912,  p.  734. 

2  Schwartz,  H.  J.:  Amcr.  Jour.  Med.  Sci.,  September,  1912,  p.  369. 

'  O'Neil,  R.  F.:  Bo.ston  Med.  and  Surg.  Jour.,  October  3,  1912,  p.  464. 

*  Irons,  E.  E.:  Jour.  Infect.  Dis.,  1908,  vol.  v,  p.  279. 

'  Reiter:  Zeitschr.  f.  Geburtsh.  u.  Kinderh.,  1911,  vol.  Ixviii,  p.  471. 

6  Irons,  E.  E.:  Jour.  Amer.  Med.  Assoc,  March  30,  1912,  p.  931. 


BACTERIOLOGY    OF   THE    GONOCOCCUS  85 

cases  an  area  of  hyperemia  5  to  10  mm.  in  diameter  appears  around 
the  point  of  inoculation,  and  that  not  infrequently  a  definite  papule 
develops.  Sakaguchi'  has  arrived  at  similar  conclusions.  Sternberg- 
concludes,  after  an  extensive  study  of  this  subject,  that  the  diagnostic 
vaccination  is  of  much  practical  aid  in  the  diagnosis  of  gonorrhea. 
In  normal  persons  used  as  a  control  either  no  reaction  occurs,  or  at 
most  a  small  area  of  redness,  2  to  3  mm.  in  diameter,  develops.  Eising^ 
recommends  intradermal  injections,  and  states  that  these  are  followed 
by  a  more  pronounced  reaction  than  either  epidermal  or  subdermal. 
This  author  states  that  the  papule  measures  from  3  to  5  mm.,  is  slightly 
tender,  and  often  surrounded  by  an  areola  5  to  10  mm.  in  diameter. 
The  papule  appears  in  from  twelve  to  twenty-four  hours  after  inocu- 
lation, and  persists  for  a  varying  period,  but  never  longer  than  one 
week.  Shngenberg,^  von  de  Velde,^  Recio,^  London,^  and  others  report 
favorably  upon  the  diagnostic  value  of  vaccine.  Like  other  tests,  this 
will,  no  doubt,  be  found  to  have  its  limitations,  and  further  research  is 
required  before  its  value  and  scope  can  be  definitely  determined. 

Leukocytosis  in  Gonorrhea. — Wile*  has  studied  the  question  of 
leukocytosis  in  cases  of  gonorrhea.  Fifty  cases  were  employed,  includ- 
ing men,  women,  and  children  suffering  from  various  lesions.  Wile 
concludes  that  gonorrhea  presents  no  typical  blood-picture,  but  varies 
with  the  individual  case,  the  stage  of  the  disease,  and  the  variety  of 
the  lesion.  In  his  series  there  was  a  slight  decrease  in  the  polynuclear 
neutrophiles,  while  the  mononuclear  were  slightly  increased. 

The  Gonococcus  and  Mixed  Infection. — Finger,  Zweifel,  Kronig, 
and  .Jadassohn'-'  state  that  genital  complications  of  gonorrhea  are 
cau.sed  by  the  gonococcus  alone,  but  that  metastatic  complications, 
like  glandular  involvements,  arthritis,  cardiac  lesions,  and  skin  ab- 
scesses, are  usually'  caused  by  a  mixed  infection.  Menge'"  believes  that 
mixed  infections  in  the  female  play  a  very  unimportant  role,  and  that 
true  mixed  infections  seldom  occur.  He  further  states  that  in  gon- 
orrhea in  the  female  complications  by  continuity  and  by  metastasis 
are  caused  by  the  gonococcus  of  Neisser  alone,  but  that  other  organ- 
isnis  have  often  Ix'cn  found,  these  being,  however,  due  to  secondary 

'  SakiiKUclii,  v.:    iJciiiiut.  W'ocliciisclir.,  T/oipziR  .and   llamliurn,  1912,  vol.  liv,  p.  71!l. 

-  StcrnborK,  A.  .J.:   (iyn.  HiindMcliau.  1!I12. 

'  HisiiiR,  E.  H.:  Mod.  Koroni,  .luiif  1,  191'J,  p  U)3S. 

'  SiiriKcnberg,  B.:  Arch.  f.  Gyn.,  licrlin,  1912,  vol.  xcvi,  No.  2. 

'  von  do  Vc'Idc,  T.  H.:  Monats.  f.  tioburt.  u.  Clyn.,  Berlin,  April,  1912,  vol.  xxxv,  No.  4. 

Krcio,  A.:   Hivi.sia  di  .Mcdicina  y  Cinirgia,  Havana,  .•\i)ril  2."),  1912. 

London,  .J.:   Anicr.  .Med.,  April,  1912. 

\\  ilc,  ,J.  S.:  .\mor.  .lour.  Med.  Scl.,  new  scries,  HKMi,  vol.  cxxxi,  p.  1().")2. 
'  FiiiKcr,    Zweifel,    Kninin,    .ladius.solin;    Quoted   hy  K.  Menne:    Ilandhucli   iler   (ie- 
Rehleehlslcrankheiten,  Vienna,  1910. 

\Unni-:    llaiidl>iicli  d.  ( liwlileclil-^kranklieilcn,  \icniia.   1910. 


86 


GONORRHEA    IN    WOMEN 


infections — as,  for  instance,  a  pyosalpinx  in  which  mixed  infection 
with  the  Bacilhis  coU  commune,  the  latter  organism  having  entered 
the  tube  secondarily  from  the  intestinal  tract.  Certainly  in  acute  cases 
pure  cultures  of  gonococcus  are  much  more  likely  to  be  obtained  than  in 
chronic  cases.  The  locahty  invaded  is  of  importance  in  this  connection, 
as  obviously  some  structures  are  more  prone  to  a  secondary  infection  with 
another  microorganism  than  are  others.  Thus  in  gonorrheal  proctitis 
the  infection  is  always  a  mixed  one,  and  the  same  is  probably  true  of 
the  oral  cavity.  This  question  of  mixed  infection  of  the  various  organs 
will  be  dealt  with  more  fully  in  subsequent  chapters.  It  is  sufficient  to 
state  here  that,  in  the  author's  opinion,  mixed  or  rather  secondaiy  in- 
fections are  by  no  means  infrequent,  especially  in  chronic  cases,  and 
when  employing  vaccine  therapy  this  fact  must  be  borne  in  mind. 


CHIEF  CHARACTERISTICS  OF  SIX  GRAM-NEGATIVE  COCCI ' 


Action  on 

Carbohydrates 

-l-  =  acid 

Oroanibm  and 

Growth  on  Nu- 

Growth  on 

--alkaline 
0  =iio  reaction 

SooncK 

TR08E  Acetic  Agar 
AT  37°  C. 

Gelatin  at  20° 

C. 

Pathogenicity 

gj 

o 

ffi 

8 
§ 
5 

Q*' 

s 

^1 

M.    catarrhalis, 

Opaque ;     granu- 

Positive. (Grows 

Mice  and  guinea- 

nasal           and 

lar. 

on      ordinary 

pigs    by   intra- 

pharyngeal dis- 

agar at  37°  C.) 

peritoneal      in- 

charge. 

oculations  only. 

— 

— 

—    — . 

M.      intracellu- 

Clear;  smooth. 

Negative. 

In     some     cases 

laris       (menin- 

mice          and 

gococcus),  cere- 

guinea-pigs   by 

brospinal  men- 

intraperitoneal 

ingitis. 

inoculations. 

-j- 

-1- 

+  — 

M.       gonorrhoeae 

No  growth  unless 

Negative. 

In     some     cases 

(gonococcus), 

blood  added. 

mice           and 

urethral       dis- 

guinea-pigs  by 

charge. 

intraperitoneal 

inoculations. 

-1- 

-1- 

0     0 

From   nasal    dis- 

Clear,     smooth, 

Negative  at  first, 

Mice  and  guinea- 

charge       from 

and      becomes 

later     posit 

ve. 

pigs    by   intra- 

Hartford's case 

yellowish. 

(Grows  on 

or- 

peritoneal      in- 

of   influenza- 

dinary agar 

at 

oculations. 

like    epidemic. 

37°  C.) 

+ 



-1- 



From    nasal    dis- 

Opaque;      gran- 

Negative. 

Mice  and  guinea- 

charge        from 

ular. 

pigs   by   intra- 

Hartford's case 

peritoneal     in- 

of    influenza- 

oculations. 

like  epidemic. 

-1- 

-f- 

-1- 

-f 

From  urethra. 

Opaque;      some- 
what granular; 
smooth  edges. 

Negative. 

Mice  and  guinea- 
pigs    by   intra- 
peritoneal     in- 

oculations. 

-1- 

-1- 

+ 

-f 

M.      melitensis 

Creamy        and 

Positive. 

Monkeys,     also 

Malta  fever. 

slightly        yel- 
lowish. 

rabbits       and 
guinea-pigs,  by 
intracerebral 

inoculation. 

0 

0 

0 

'  From  Dunn  and  Gordon,  Brit.  Med.  Jour.,  1905,  vol.  ii,  p.  427. 


CHAPTER  III 

PATHOLOGIC   CHANGES   PRODUCED  BY  THE  GONOCOCCUS   IN 
THE  FEMALE  GENITAL  TRACT 

In  no  disease,  perhaps,  is  a  more  thorough  knowledge  of  path- 
ology necessary  for  an  intelligent  comprehension  and  studj*  of  the 
symptoms  and  treatment  than  in  gonorrhea.  It  is  the  author's  belief 
that  the  pathology,  symptomatology,  and  treatment  of  any  given  dis- 
ease should  be  studied  coincidentally,  for  only  in  this  way  can  the  three 
branches  be  satisfactorih^  understood.  In  order  for  the  clinician  and 
the  pathologist  to  reap  the  greatest  benefit  from  their  labor,  the  lab- 
oratory and  the  cUnic  should  be  closely  associated.  Given  a  thorough 
knowledge  of  the  pathologj',  the  symptoms  resulting  from  the  patho- 
logic changes  can  be  more  or  less  closely  worked  out.  For  example, 
the  symptoms  and  recurrent  character  of  BarthoUn's  abscess  are  en- 
tirely explained  by  a  study  of  the  histology  and  anatomy  of  the  gland. 
The  same  may  be  said,  in  a  somewhat  broader  sense,  of  those  numerous 
and  varied  lesions  generally  classified  under  the  heading  of  Pelvic 
Inflammatory  Disease.  The  patulous  tube,  with  its  leakage  of  in- 
fected material,  is  productive  of  active  pelvic  peritonitis,  with  its  ac- 
companj'ing  symptoms;  the  closed  tube,  with  its  perhaps  more  mas- 
sive pathology,  and  its  often  less  marked  subjective  symptomatology; 
the  sterilitj'  due  to  endometritis  or  the  occlusion  of  the  tube  or 
interference  with  the  maturation  and  rupture  of  the  Graafian  follicle; 
the  adhesions  to  the  bladder  or  rectum,  with  their  accompanying  dys- 
uria  or  rectal  symptoms,  are  also  thus  explained.  So  almost  the 
entire  category  of  symptoms  may  be  elucidated  by  a  study  of  the 
pathology  of  the  individual  case.  A  correlation  of  the  pathology  and 
the  symptomatology  is,  therefore,  of  the  greatest  advantage.  In  the 
same  way  a  knowledge  of  the  pathology  is  of  great  aid  in  selecting  the 
best  form  of  treatment. 

In  previous  pages  an  attempt  has  been  made  to  depict  the  method 
of  invasion  of  the  gonococcus  to  the  genital  tract  of  the  female  and  the 
type  of  lesions  produced.  The  infection  almost  invariably  begins  as 
a  surface  inflammation,  and  spreads  thence  more  or  loss  deeply  into 
the  underlying  structures.  The  gonococcus  may  lie  dormant,  es- 
pecially in  areas  below  the  internal  os,  for  a  prolonged  jieriod,  but  if 

87 


88  GONORRHEA    IN    WOMEN 

the  proper  stimulus  is  applied,  it  is  ready  to  spring  into  activity.  On 
the  other  hand,  protracted  encapsulation,  such  as  frecjuently  occurs  in 
the  adnexa,  tends  to  destroy  the  organism.  In  the  latter  location  the 
prolongation  of  symptoms  may  be  traced  to  three  definite  causes: 
reinfection,  either  autoinfection,  from  the  cervix  and  endometrium, 
or  from  without,  may  occur;  or  secondary  infection  may  result  and  the 
lesions  be  actively  continued  by  organisms  other  than  the  gonococcus; 
and,  lastly,  the  scar  tissue  or  adhesions  resulting  from  the  active  in- 
fection may  persist  and  produce  symptoms. 

Many  more  or  less  indirect  results  of  gonorrhea  also  occur.  Thus 
the  gonococcus  is  believed  to  prepare  the  soil  for  subsequent  infec- 
tions, such  as  tuberculosis,  or  for  the  pyogenic  organism;  tubal  carci- 
noma seldom  occurs  in  previously  normal  tubes,  whereas  the  loss  of 
cilia  in  the  tubal  epithelium  and  kinks  of  the  tube  resulting  from  ad- 
hesions are  known  to  be  strong  predisposing  factors  of  tubal  pregnancy. 

In  .localities  invested  by  adult  squamous  epithelium,  such  as  the 
vagina,  the  gonococcus  rarely  produces  serious  lesions,  the  inflammation 
being  usually  due  to  the  irritating  toxin-laden  discharge  constantly 
passing  over  the  surface.  It  is  true  that  gonococci  may  occasionally 
be  fovmd  in  the  depth  of  and  among  the  cells  of  the  squamous  epi- 
thelium, but  the  organisms  do  not  appear  to  thrive  in  these  areas. 
On  true  mucosa,  however,  a  different  condition  exists:  the  surface 
epithelium  becomes  swollen,  and  the  cells  become  separated  from  one 
another  by  the  inflammatory  exudate.  Many  of  the  cells  are  desqua- 
mated, and  are  ultimately  replaced  by  a  modified  epithelium — in 
some  instances  non-ciliated  columnar,  and  in  others  even  by  squamous, 
epithelium;  or  cicatricial  tissue  may  result.  The  gonococci  quickly 
gain  access  to  the  glands,  in  which  similar  changes  occur  in  the  invest- 
ing cells.  As  a  result,  periglandular  inflammation  is  usually  a  marked 
feature.  In  some  instances  the  gland-openings  become  occluded  and 
finally  become  filled  with  inflammatory  exudate,  resulting  in  the  for- 
mation of  the  pseudo-abscesses  of  Jadassohn.  As  the  process  advances, 
the  epithelium  and  its  basement-membrane  may  be  entirely  destroyed, 
and  a  true  abscess,  surrounded  by  a  pyogenic  membrane,  may  occur. 
This  condition  is  not  infrequently  seen  on  the  vulvovaginal  gland,  or 
the  deeper  epitheUum  of  the  gland  may  escape  or  be  but  temporarily 
involved,  and,  as  a  result,  occlusion  cysts  are  found.  A  similar  pathol- 
ogy may  occur  in  the  cervix,  and  to  a  less  marked  extent  in  the  cor- 
poreal endometrium  or  the  mucosa  of  the  tube.  The  gonococci  in  the 
glands  may  persist  long  after  a  surface  cure  has  been  obtained,  or  may 
from  this  location  tend  to  aggravate  the  surface  inflammation  by  re- 
infection.    This  tendency  to  glandular  penetration  possessed  by  the 


PATHOLOGIC    CHANGES    PRODUCED    BY    THE    GONOCOCCUS  89 

gonococcus  is  of  importance  in  considering  the  treatment  of  the  dis- 
ease, and,  to  a  large  extent,  accounts  for  the  resistance  to  gonococcids 
as  ordinarily  applied  to  the  surface  mucosa. 

From  the  surface  and  glands  the  gonococcus  escapes  to  the  stroma 
of  the  mucosa,  and  thence  to  the  underlying  muscular  layer,  or  even, 
in  severe  cases,  to  the  serosa  or  adjacent  structures.  As  a  result,  the 
stroma  of  the  mucosa  and  the  underlying  tissue  become  swollen  and 
infiltrated  with  inflammatory  products  and  the  blood-vessels  become 
congested.  These  changes  vary  with  the  stage,  severity  of  the  dis- 
ease, and  the  area  attacked.  As  a  result  of  desquamation  of  the  sur- 
face epithelium  or  long-continued  inflammation  in  the  depths  of  the 
mucosa  or  underlying  tissues,  cicatrices  maj'  be  formed,  and  by  their 
contractile  properties  produce  pathologic  changes  and  a  continuance 
of  symptoms  long  after  all  signs  of  active  inflammation  have  subsided. 
This  fact  is  of  especial  importance  when  considering  the  symptomatol- 
ogj^  and  treatment  of  intraperitoneal  pelvic  lesions.  By  this  process 
an  extensive  pathology  may  be  greatly  curtailed,  and  result  in  "the 
derehcts  of  the  gonococcal  storm,"  as  they  have  been  aptly  termed  by 
Sanger.  There  is  no  doubt  that  but  for  this  tendency  toward  the 
formation  of  scar  tissue,  the  proportion  of  cases  of  pelvic  inflammatory 
disease  ultimately  requiring  operative  intervention  after  properly  carried 
out  palliative  treatment  would  be  greatly  reduced.  In  other  words, 
many  old,  chronic  cases  suffer  more  markedly  from  adhesions  and  con- 
tractions than  from  the  actual  infection.  This,  of  course,  does  not 
apply  to  those  cases — and  thoy  are  many — that  exhibit  more  or  less 
frequent  or  prolonged  exacerbations. 

From  the  method  of  invasion,  the  most  marked  ])athologic  change 
is  usually  found  near  the  surface.  The  tissue  in  tliis  locality  seldom 
undergoes  complete  resolution,  evidences  of  past  disturbances  nearly 
always  remaining.  The  chief  characteristic  of  gonococcal  inflamma- 
tion is  its  chronicity.  The  much  mooted  question,  as  to  whether  or 
not  the  gonococcus  produces  lesions  suflRciently  characteristic  to  dif- 
ferentiate them  from  other  forms  of  infection,  without  a  study  of  the 
bacteriology  of  the  individual  case,  will  be  more  thoroughly  discussed 
in  subsecjuent  pages. 

GONORRHEAL  VULVITIS 
Vulvitis  in  the  adult  is  a  not  infrequent  accompaniment  of  gon- 
orrhea of  the  cervix  or  urethra.  In  infants  and  young  children  the 
infection  usually  spreads  to  the  vagina,  producing  a  vulvovaginitis. 
In  the  young,  on  account  of  the  delicacy  of  the  skin  over  the  affected 
areas,  the  lesions  are  likely  to  be  more  i)r()n()unccd.     (Sonorrhea  may 


90  GONORRHEA    IN    WOMEN 

produce  the  most  severe  grade  of  vulvitis.  During  the  acute  stage  the 
labia  majora  and  minora,  the  clitoris,  and  the  adjacent  structures  are 
reddened,  swollen,  and  tender.  The  affected  area  is  bathed  in  a  more 
or  less  profuse  purulent  discharge,  which  contains  numerous  gonococci. 
The  chronic  vulvitis,  which  often  continues  after  the  acute  process  has 
subsided,  is  characterized  by  similar  symptoms,  all  of  which  are,  how- 
ever, less  pronounced.  Although  some  redness  usually  persists,  the 
edema  and  swelling  are,  as  a  rule,  less  marked,  and  tenderness  is  either 
absent  or  greatly  decreased.  The  discharge  is  yellowish  or  brownish 
in  color,  thick,  but  less  profuse,  and  contains  fewer  gonococci  than 
during  the  acute  stage.  In  neglected  or  careless  patients  yellowish  or 
brownish  crusts  may  form,  and  in  severe  cases,  when  these  are  removed, 
bleeding  ulcers  may  be  found  beneath.  Evidences  of  Bartholinitis 
and  of  urethritis  can  generally  be  found.  Condylomata  are  not  in- 
frequent, especially  in  neglected  cases  or  when  pregnancy  is  present. 
Histology. — The  histology  resembles  that  of  an  ordinary  dermati- 
tis, and  varies  in  acuteness  and  extent  of  involvement  according  to  the 
individual  case  and  the  stage  of  the  infection. 

INFLAMMATORY  LESIONS  OF  BARTHOLIN'S  GLAND 
Bartholin's  glands  (named  after  Bartholinus,^  who  described  these 
structures  in  detail  in  the  seventeenth  century)  are  structures  usually 
about  3  to  5  cm.  in  length,  and  having  a  diameter  of  2  to  4  mm.  The 
ducts  vary  somewhat  in  length,  but  average  about  1.5  cm.,  and  at  the 
outlet  have  a  diameter  of  about  0.5  mm.,  but  widen  as  the  gland  is 
approached.  In  their  widest  portion  they  have  a  diameter  of  about  2 
or  2.5  mm.  Before  reaching  the  gland  the  duct  divides  into  two  or 
three  trunks,  which  in  turn  subdivide  so  that  finally  each  lobule  of  the 
gland  is  drained  by  a  small  duct.  The  gland  and  its  ducts  have 
been  appropriately  likened  to  a  bunch  of  grapes  somewhat  more 
developed  on  one  side  than  on  the  other,  the  duct  representing  the 
stem,  and  the  lobules,  the  grapes.  The  outer  part  of  the  duct  is  lined 
by  multiple  layers  of  squamous  epithelium.  In  the  deeper  portions 
transitional  epithelium  is  present.  The  small  ducts  which  finally  enter 
the  gland  present  a  somewhat  varying  histologic  picture:  in  some  in- 
stances they  are  lined  b}^  transitional  epithelium;  in  others,  by  cylin- 
dric  or  cuboid  cells.  On  cross-section  the  glands  are  found  to  be 
round  or  oval,  and  are  invested  by  a  single  layer  of  high  cylindric 
epithelium.  These  cells  often  contain  large  quantities  of  mucus,  and 
under  these  conditions  are  of  the  goblet  type,  and  are  not  dissimilar  to 
the  glandular  elements  of  the  cervix,  except  that  the  protoplasm  does 
1  Huguier:  Memoires  de  I'Academie  de  M(5decine,  Paris,  1856,  vol.  xv,  p.  531. 


I 


PATHOLOGIC    CHANGES    PRODUCED    BY   THE    GONOCOCCUS  91 

not  take  the  hematoxylin  stain.  The  glands  are  tubular  or  racemose, 
and  are  contained  in  a  thick  framework  of  connective  tissue  and  non- 
striped  muscle.  The  glands  and  adjacent  tissue  are  rich  in  blood- 
vessels. 

Bartholinitis  may  occur  independently,  or  as  an  accompaniment 
of  \ailvitis.  Although  theoretically  cysts  and  other  manifestations  of 
barthohnitis  maj'  be  the  result  of  various  forms  of  infection,  if  carefully 
studied,  the  great  majority  of  cases  can  be  traced  to  gonorrhea.  Of 
14  specimens  of  cysts  and  21  specimens  of  abscesses  of  this  structure 
in  the  Gynecological  Laboratory  of  the  University  of  Pennsjdvania, 
all  were  clinically  associated  with  gonorrhea.  Veit^  beheves  that 
barthohnitis  is  nearlj'  always  of  gonorrheal  origin.  Suppurative  proc- 
esses are,  however,  frequently  due  to  mixed  infection.  As  a  result  of 
gonorrheal  infection  of  Bartholin's  gland,  various  lesions  may  be  pro- 
duced. More  or  less  well-marked  redness  and  swelling,  often  somewhat 
resembUng  a  mosquito-bite, — the  so-called  gonococcal  maculfe  of 
Sanger, — are  present  about  the  exit  of  the  gland  whenever  the  struc- 
ture becomes  inflamed.  The  gonococcal  maculse  persist  for  prolonged 
periods,  even  after  lengthy  intervals  of  quiescence  of  the  disease. 

Cyst. — In  1861  Breton-  described  cysts  of  Bartholin's  gland,  this 
being,  perhaps,  the  earliest  description  of  these  lesions.  If  the  in- 
flammation is  limited  to  the  duct  of  the  gland,  partial  or  entire  occlu- 
sion of  this  structure  may  result,  and  be  followed  bj'  the  formation  of  a 
retention  cyst.  Cj^sts  of  Bartholin's  gland  may  occur  in  the  duct  or 
in  the  gland,  or  both  structures  may  be  involved,  depending  upon  the 
situation  of  the  occlusion.  The  tumors  may  be  unilateral  or  bilateral, 
the  former  being  the  more  common.  Cj'sts  due  to  occlusion  of  the 
orifice  of  the  duct  are  of  the  most  frequent  variety,  and  are  always 
unilocular.  These  tumors  are  pyriform  in  shape,  the  large  end  being 
directed  downward.  \Miile  iti  situ,  if  the  tumor  is  of  moderate  or 
large  size,  the  vulvar  cleft  is  distorted.  These  cysts  are  usually  about 
the  size  of  a  pigeon's  egg,  and,  as  a  rule,  grow  slowly,  although  rapid 
increase  in  size  is  sometimes  noted.  This  may  in  some  instances  be 
due  to  hemorrhage  occurring  in  the  cavity  of  the  cyst.  When  a  cyst 
of  the  duct  is  present,  the  gland  is  pushed  upward  and  outward. 
Cysts  of  the  gland  proper  are,  as  a  rule,  more  spheric,  nioi-e  deeply 
placed  than  cysts  of  the  duct,  and  show  a  tendency  to  extend  into  the 
rectovaginal  septum.  Cj'sts  that  occur  in  the  gland  or  in  the  depths  of 
the  duct  where  it  has  subdivided  may  be  multii)le.  Cullen''  reported 
a  series  of  17  cysts  of  Bartholin's  gland.  •  The  smallest  of  these  was 

'Veil:  Ilanrlbuch  (ler  Gyniikologie.  'Breton:  Th6se  de  Stra.shourg,  1861. 

'  Cullen,  T.  C:  Jour.  Amor.  Med.  As.soc.,  .lamiary  21,  1905,  p.  204. 


92  GONORRHEA    IN   WOMEN 

5  mm.  in  diameter,  and  the  largest,  4  cm.  Kleinwaditer^  asserts  that 
retention  cysts  of  this  locahty  are  rarely  larger  than  a  hen's  egg.  In 
the  author's  series  of  14  cases,  the  largest  was  8  cm.  in  diameter,  and 
all  were  unilateral.  Small  cysts  produce  no  subjective  symptoms, 
and  patients  are  frequently  not  aware  of  their  presence.  They  are, 
however,  not  infrequently  observed  during  the  routine  gynecologic 
examination,  and  are  quite  often  discovered  accidentally  while  per- 
forming plastic  operations  on  the  perineum.  Wiener-  has  reported  the 
history  of  an  unusual  case  in  which  the  cysts  were  bilateral  and  meas- 
ured respectively  11x8  and  12  x  5  cm.  An  unusually  large  specimen 
of  this  form  of  growth  has  recently  been  described  by  Dartigues.^ 
If  removed  without  rupture  or  when  examined  in  situ,  the  cysts  are 
moderately  tense  and  fluctuant.  After  removal  the  outer  surface  is 
roughened  at  the  point  where  the  tumors  have  been  shelled  out  or 
dissected  free  from  their  bed  of  adhesions.  On  section,  the  walls  are 
found  to  vary  quite  markedly  in  thickness  in  different  specimens  and 
in  different  parts  of  the  same  specimen.  The  walls  are,  as  a  rule, 
moderately  dense.  The  lining  is  generally  smooth,  although  some  cir- 
cular or  crescent-shaped  openings  are  often  present,  indicating  dilated 
gland  openings.  The  cysts  are  usually  unilocular,  although  occasion- 
ally two  or  more  cavities  are  present,  this  point  depending  upon  the 
location  of  the  occlusion.  The  cyst  contents  generally  consist  of  clear 
serous  fluid,  but  they  may  be  of  a  chocolate  color,  owing  to  the  ad- 
mixture of  blood.  As  a  result  of  infection,  the  contents  are  sometimes 
turbid  or  purulent. 

Histology. — The  microscopic  picture  varies  ciuite  widely  in  different 
specimens.  As  a  rule,  areas  of  comparatively  normal  gland  are  pres- 
ent. The  cyst  lining  differs  according  to  the  point  of  origin  of  the 
cyst.  If  the  cyst  is  due  to  the  occlusion  of  the  main  duct  near  the 
outlet,  the  investing  epithelium  will  naturally  be  largely  squamous  in 
type,  whereas  if  the  occlusion  has  been  in  one  of  the  secondary  ducts, 
the  lining  epithelium  may  be  transitional  or  cyUndric.  Not  in- 
frequently all  varieties  of  cells  are  present  in  different  portions  of  the 
cyst.  In  large  cysts,  in  those  of  long  standing,  or  in  those  in  which 
marked  intracystic  tension  has  been  present,  the  investing  epithelium 
is  flattened  or  may  be  largely  absent.  The  walls  of  the  cysts  are  rich  in 
blood-vessels,  and  are  composed  of  unstriped  muscle  and  fibrous  connec- 
tive tissue.  Only  rarely  can  gonococci  be  recovered  from  the  contents 
of  the  cyst,  for  prolonged  encapsulation  tends  to  destroy  this  organism. 

'  Kleinwachter:  Zeit.  f.  Geb.  u.  Gyn.,  vol.  xx.xii,  p.  191. 
-  Wiener,  S.:  Amer.  Jour.  Obst.,  February,  1912,  p.  243. 
'  Dartigues:  Paris  Chirurg.,  1911,  vol.  iii,  p.  565. 


PATHOLOGIC    CHANGES    PRODUCED    BY    THE    GONOCOCCUS  93 

Bartholinitis. — If  occlusion  does  not  occur  in  the  duct,  and  the  in- 
fection extends  to  the  gland,  inflammatory  changes  are  here  set  up. 
The  gland  becomes  enlarged,  infiltrated  with  inflammatory  products, 
and  presents  the  usual  clinical  and  pathologic  characteristics  of  adeni- 
tis. This  stage  may  become  chronic,  with  the  formation  of  more  or 
less  connective  tissue,  so  that  the  gland  is  easily  palpable  while  in  situ 
as  a  firm,  oblong,  flattened  body. 

Abscess  of  Bartholin's  Gland. — Not  infrequently,  however,  the 
inflammation  advances  to  pus  formation,  and  a  Bartholin's  abscess 
results.  When  this  occurs,  only  rarely  is  the  entire  gland  equally 
involved.  As  a  rule,  one  or  more  lobules  are  affected,  and  when  the 
abscess  ruptures  or  is  incised,  healing  tends  to  occur  without  eradica- 
tion of  the  infection,  so  that  at  a  subsequent  date,  often  as  the  result 
of  slight  trauma  or  of  reinfection  with  virulent  microorganisms,  or 
sometimes  for  no  apparent  reason,  suppuration  develops  in  other 
lobules.  The  history  of  a  number  of  abscesses  occurring  in  this  lo- 
cality and  extending  sometimes  over  a  considerable  period  of  time  is 
pathognomonic  of  this  condition,  and  is  due  to  suppuration  first  of  one 
lobule  and  then  of  another.  The  entire  gland  must  be  removed  if 
a  permanent  cure  is  to  be  effected.  Macroscopically,  the  abscesses 
appear  as  small,  ovoid  or  round,  purulent  collections,  rarely  larger 
than  a  bantam's  egg,  and  more  often  about  the  size  of  an  English 
walnut.  The  abscesses  are  situated  rather  deeply,  and  involve  the 
lower  portion  of  the  labia,  extending  backward  toward  the  perineum. 
Sometimes  there  is  considerable  swelling  and  induration  surrounding 
the  abscess,  whereas  at  other  times  there  is  comparatively  little.  In 
some  ca.ses  pus  may  be  squeezed  out  of  the  duct.  The  walls  are,  as  a 
rule,  thick,  and  the  lining  not  infrequently  presents  a  septate  appear- 
ance. The  contents  consist  of  moderately  thick,  yellowish  or  green- 
ish pus.  which  is  often  blood  stained. 

Hishildi/i/.  The  gland  and  the  surrounding  tissu(>  are  infiltrated 
with  acute  or  subacute  infiannnatorj'  products.  The  epithelium  of 
the  gland  presents  the  usual  inflannnatory  cluinges.  The  blood- 
vessels are  engorged,  and  freciuently  the  inflannnatory  changes  are 
found  following  along  the  course  of  the  lymphatics.  The  pus  in  these 
abscesses  contains  gonococci,  and  not  infrecjuently  other  micnxirgan- 
isms  are  present;  indeed,  some  writei's  assert  that  mixed  infection  is 
always  present  in  supi)urati\'e  in'occsscs  of  tills  locality. 

CONDYLOMATA  ACUMINATA 
Condylomata  acuminata,  or  venereal  warts,  of  gonorrheal  origin, 
arc  the  result  of  irritation  produced  by  the  more  or  less  constant 


94  GONORRHEA    IN    WOMEN 

bathing  of  the  parts  with  the  leukorrheal  discharge.  They  are  pap- 
illary outgrowths  that  appear  on  the  external  genitaUa  and  occasion- 
ally on  the  vagina  or  cervix.  The  tumors  may  spring  from  the  per- 
ineum, labia  majora  or  minora,  or  other  adjacent  structures.  The 
growths  vary  in  size  from  those  of  microscopic  dimensions  to  those  the 
size  of  a  man's  fist  or  larger.  The  history  of  an  unusually  extensive 
case  has  recently  been  reported  by  Rassegna.^  Multiple  growths  are 
the  rule,  and  tumors  of  various  sizes  are  usually  present  in  the  same 
ease.  The  tumors  are  composed  of  localized  hypertrophies  of  the  outer 
layers  of  the  skin,  and  are  whitish,  pinkish,  or  purplish,  wart-like, 
cauliflower-shaped  masses,  sometimes  distinctly  pedunculated,  and  in 
other  instances  springing  from  a  broad  base.  The  tumors  originate  as 
discrete  outgrowths,  but  frequently  they  coalesce.  The  surface  of  the 
tumors  and  the  surrounding  skin  are  bathed  by  a  thin,  irritating, 
offensive  discharge.  Condylomata  acuminata  of  gonorrheal  origin 
usually  possess  a  distinctly  pointed  apex,  in  contradistinction  to  syphi- 
litic condylomata,  which  are  flattened,  and  only  rarely  tend  to  become 
pedunculated.  Gonorrheal  condylomata  acuminata,  when  situated 
within  the  vagina,  are  often  flattened  as  a  result  of  pressure,  and  fre- 
quently present  a  somewhat  macerated  appearance.  As  a  result  of 
the  irritating  discharge,  the  cutaneous  surface  surrounding  the  ex- 
crescences is  often  reddened. 

Histology. — The  tumors  are  composed  of  hypertrophies  of  the  outer 
layers  of  the  skin,  the  papillse  forming  the  chief  constituents  of  the 
growths.  They  are  moderately  well  supplied  with  blood-vessels,  and 
upon  their  vascularity  and  the  thinness  of  the  outer  layers  of  epithe- 
lium depend,  to  a  large  extent,  their  color  and  the  amount  of  discharge 
they  produce.  The  connective  tissue  surrounding  the  tumors  gen- 
erally presents  a  moderate  degree  of  chronic  inflammatory  reaction. 

VAGINITIS 
The  vagina  is  lined  by  a  modified  skin  and  normally  contains  but 
few  glands.  Cullen,  v.  Preuschen,  Hennig,  and  others  have  demon- 
strated conclusively  the  presence  of  glands  in  the  vaginal  hning,  and 
have  also  proved  their  relative  scarcity.  In  the  young  the  outer  layer 
of  the  stratified  squamous  epithelium  is  ill  developed,  and  this  fact 
accounts,  to  a  large  extent,  for  the  frequency  of  acute  vaginitis  in 
children.  As  puberty  is  approached  the  epithehal  layer  becomes 
thicker  and  more  dense  and  an  attempt  is  made  toward  the  formation 
of  an  outer  horny  layer,  such  as  is  found  in  the  skin  proper,  and,  as  a 
result,  acute  vaginitis  during  active  sexual  life  is  infrequent.     At  the 

'  Rassegna:  Jour,  d'obst.  e  ginec,  Naples,  1911,  vol.  xx,  217. 


PATHOLOGIC    CHANGES    PRODUCED    BY    THE    GONOCOCCUS  95 

menopause  atrophic  changes  occur,  and  doubtless  partially  explain 
the  greater  susceptibihty  of  the  vagina  to  infection  at  this  tinie. 

During  the  acute  stage  the  vaginal  lining  is  reddened,  swollen, 
edematous,  and  bathed  in  a  creamy,  yellowish,  purulent  discharge, 
which  may  be  blood-streaked.  The  normal  acid  reaction  of  the  vagi- 
nal secretion  is  diminished  or  may  even  be  alkaUne.  In  the  chronic 
stage,  especially  in  the  young,  the  vaginal  mucosa  presents  a  granular 
appearance,  due  to  localization  of  the  inflammation  to  various  groups 
of  papilla?.  Ulcers  or  small  excoriations  are  not  infrequent,  and  when 
of  gonorrheal  origin,  are  often  present  in  the  vaginal  vault.  Gon- 
orrheal vaginitis  cannot  with  certainty  be  distinguished  by  the  macro- 
scopic appearance  from  other  forms  of  inflammation.  In  long-con- 
tinued cases  vaginitis  condylomatosa  may  be  present.  The  growths 
are  much  less  frequent,  of  smaller  size,  and  are  more  discretely  dis- 
tributed than  when  occurring  on  the  external  genitalia. 

Histology. — The  various  layers  of  the  vaginal  mucosa  are  swollen 
and  infiltrated  with  inflammatory  products.  In  chronic  cases  the  in- 
flammation often  shows  a  tendency  to  localize  in  certain  groups  of 
papillae  in  the  subepithelial  tissue.  In  some  instances  the  epithe- 
lium may  desquamate,  producing  small  ulcers  that  may  extend  to 
the  underlj'ing  connective  tissue.  Immediately  beneath  the  layer  of 
stratified  squamous  epithelium  is  usually  found  a  well-defined  zone  of 
inflammatorj'  reaction,  characterized  by  an  infiltration  of  small  round- 
cells,  polymorphonuclear  leukocytes,  serum,  and  congested  capil- 
laries. Small  round-cells  and  polj^morphoimclear  leukocytes  are  also 
often  present  in  the  protective  epithelium. 

URETHRITIS 
The  infection  originates  at  or  just  within  the  external  urinarj' 
meatus.  During  the  acute  stage  the  mucosa  of  the  external  meatus  is 
swollen  and  reddened,  and  may  be  found  protruding  a  short  distance 
from  the  urethra.  Further  examination  reveals  the  fact  that  the 
mucosa  of  the  canal  is  inflamed.  INIilking  the  urethra  jiroduces  a  con- 
siderable quantity  of  creamy  yellowisli  pus,  which  contains  typical 
gonococci  in  large  numbers.  The  urethra  itself  is  tender,  and  may  be 
felt  as  a  more  or  less  indurated  l)and  lying  beneatli  the  vaginal  nuicosa. 
As  the  disease  becomes  chronic  the  discharge  diminishes,  becomes 
milky  or  mucopurulent  in  character,  and  in  some  cases  disappears 
almost  entirely.  The  gonococci  are  fewer  in  number,  and  under 
ordinary  circumstances  it  may  be  impossible  to  obtain  typical  micro- 
organisms. The  mucosa  of  the  urethra  may  be  slightly  thickened  or 
may  a{)pear  normal.     Skene's  and  Schiillcr's  glaiuls  are,  however, 


96  GONORRHEA    IN    WOMEN 

nearly  always  reddened  and  prominent,  and  upon  pressure  a  small 
amount  of  pus  can  usually  be  extruded.  The  urethra  at  this  stage 
may  feel  normal  to  the  examining  finger,  or  a  certain  amount  of  peri- 
urethral infiltration  may  be  present.  The  latter  is  generally  the  case 
in  long-standing  chronic  cases.  Abscesses  may  form  in  Skene's, 
Schiiller's,  or  in  any  of  the  mucous  glands  of  the  urethra  in  either  the 
acute  or  the  chronic  stage.  The  abscesses  are  usually  on  the  floor  of 
the  anterior  portion  of  the  urethra,  and  tend  to  bulge  into  the  vagina. 
More  or  less  complete  evacuation  of  the  contents  of  the  abscess  into 
the  urethra  can  often  be  accomplished  by  pressure  through  the  vagina. 
As  a  result  of  long-standing  inflammation  the  mucous  glands  some- 
times become  obliterated,  and  under  such  circumstances  these  struc- 
tures can  often  be  felt  immediately  beneath  the  urethra  as  hard, 
indurated  bodies.     A  caruncle  may  develop. 

Histology. — Specimens  of  urethritis  are  rarely  seen  in  the  labora- 
tory, but  when  observed,  are  found  to  present  the  usual  evidences  of 
inflammation,  the  histologic  picture  varying  according  to  the  portion 
of  the  urethra  examined  and  the  stage  of  the  disease.  The  inflamma- 
tory changes  are  most  persistent  in  the  glands  in  the  anterior  portion 
of  the  floor  of  the  urethra. 

CERVICITIS 
Gonorrheal  infection  of  the  cervix  is  extremely  frequent,  and,  ac- 
cording to  Menge,^  is  found  in  about  80  per  cent,  of  all  acute  and  in 
95  per  cent,  of  all  chronic  cases.  The  gonococcus  exhibits  a  marked 
predilection  for  columnar  epithelium,  and  a  comparative  protective 
influence  is  exerted  by  squamous  epithelium,  especially  the  fully  de- 
veloped squamous  epithelium  of  the  adult.  The  portio  vaginahs  is 
normally  covered  by  multiple  layers  of  stratified  squamous  epithelium, 
and  is,  therefore,  rarely  if  ever  primarily  involved.  Anatomic  re- 
search has  demonstrated  the  fact  that  the  squamous  epithelium  usually 
extends  upward  in  the  cervical  canal  to  about  the  external  os.  Cul- 
len,^  Ruge,^  and  others  have  shown  that  this  is  a  variable  point.  In 
some  cases  the  squamous  epithelium  extends  upward  nearly  to  or 
even  above  the  internal  os,  whereas  in  other  cases  the  point  of  junction 
of  the  two  types  of  epithelium  is  considerably'^  outside  the  external  os. 
From  the  vaginal  wall  to  the  external  os  the  squamous  epithelium  grad- 
ually thins  out  until,  at  the  point  of  junction  with  the  cyhndric  epi- 

'  Menge,  K.:   llaiulbuch  der  Geschlechtsk.,  Vienna,  1910. 
■  Cullen,  T.  S. :  Cancer  of  the  Uterus,  1900,  p.  17. 

2  Winter,  G.,  and  Ruge,  C. :  A  Text-book  of  Gynecological  Diagnosis.  Translated 
after  third  revised  edition,  Philadelpliia  and  London. 


:::^ 


Fig.  2. — Endocebvicitih. 
The  section  has  been  takc-u  through  the  mucosa  of  the  cervical  ranal.     The  surface  epithehum  is,  for 
the  most  part,  desquamated.     The  superficial  layers  of  the  mucosa  are  infiltrated  with  atx  inflammatory  exudate. 
!ii  the  deeper  portions  of  the  glands  the  epithelium  is  somewhat  degenerated,  and  a  well-<lefined  periglandular 
inflammation  is  present.     The  pathologic  changes  are,  however,  most  marked  near  the  surface  ( X  50). 


PATHOLOGIC    CHANGES    PRODUCED    BY    THE    GONOCOCCU.S  97 

thelium,  it  is,  as  a  rule,  not  more  than  half  as  thick  as  at  the  vagino- 
cervical  junction.  In  some  cases  the  cylindric  epithelium  is  of  a 
slightly  papillary  character,  and  extends  outward  over  the  portio — 
the  so-called  congenital  erosion.  Theoretically,  therefore,  women  in 
whom  the  squamous  epithelium  is  thin;  those  in  whom  the  squamous 
epithelium  extends  only  to  the  external  os;  and  those  in  whom  the  so- 
called  congenital  erosions  are  present,  should  be  more  susceptible  to 
gonorrheal  cervicitis  than  those  in  whom  the  squamous  epithelium  is 
thick,  and  in  whom  it  extends  deeply  into  the  cervical  canal.  Gon- 
orrheal infection  tends  to  locaUze  itself  in  the  true  mucosa  of  the  cer- 
vical canal,  and  if  extension  upward  occurs,  this  takes  place  at  a  men- 
strual period,  or  during  or  immediately  subsequent  to  the  emptying  of 
a  pregnant  uterus.  In  other  words,  in  the  great  majority  of  cases  the 
infection  originates  as  an  endocervicitis,  the  chief  symptom  of  which 
is  a  cervical  leukorrhea  produced  by  a  hj^persecretion  of  the  cervical 
glands  incident  to  the  inflammation.  As  a  result  of  swelling  and  hy- 
peremia of  the  mucosa  of  the  canal,  not  infrequently  a  portion  of  this 
will  project  beyond  the  external  os,  and  in  chronic  or  severe  cases  the 
inflammation  itself  may  involve  the  adjacent  squamous  epithelium  of 
the  portio,  so  that  on  examination  the  external  os  appears  as  a  bright- 
red  spot  surrounded  by  an  infiltrated,  granular  area  of  more  or  less 
limited  extent,  and  bathed  in  an  abundant  thick  mucus  or  mucopuru- 
lent discharge.  Gottschalk'  explains  the  presence  of  cylindric  epi- 
thelium in  the  portio — the  so-called  "erosion"  due  to  gonorrhea — by 
stating  that  the  glands  found  in  these  inflammatory  processes  are  true 
ectopic  cervical  glands.  The  normal  stratified  squamous  epithelium 
of  the  portio  is  pushed  away  by  extravasated  blood,  by  a  copious  in- 
filtration of  small  round-cells,  and  sometimes  by  the  rupture  of  an 
underlying  retention  cyst.  The  denuded  surface  of  the  portio  becomes 
rapidly  covered  by  the  mucosa  from  the  canal,  and  by  ectopic  cervical 
gland  epithelium  from  glands  that  open  upon  the  denuded  area.  In 
some  in.stances  newly  formed  stratified  squamous  epithelium  is  pushed 
off  by  an  extension  of  the  mucosa  of  the  canal.  Naturally,  the  picture 
varies  (juite  markedly  in  different  individuals  and  in  the  nuUiparous 
and  the  nuiltiparous.  Retention  cysts,  formed  from  tlie  cervical 
glands  and  varying  in  size  from  a  few  millimeters  in  diameter  to  the 
size  of  a  pea  or  even  larger,  are  often  present.  True  macroscopic 
erosions  of  gonorrheal  origin  are  extremely  rare. 

Hist()lo(/y. — The  chronicity  of  gonorrheal  cervicitis  can  be  entirely 
explained  by  a  study  of  the  histology  of  this  organ.  In  the  sexually 
mature  individual  the  cervical  canal  is  lined  by  high  cylindric  ('jjithe- 

'Collsclialk,  S.:   Ilrit.  Med.  .lour.,  October  22,  1910. 


98  GONORRHEA    IN   WOMEN 

Hum,  a  type  of  tissue  peculiarly  susceptible  to  gonorrhea.  The  secre- 
tion of  the  canal  is  weakly  alkaline  in  reaction.  The  walls  of  the  canal 
are  irregular,  and  for  the  most  part  are  composed  of  heaped-up  mu- 
cosa, known  as  the  arbor  vitse  and  the  pUcse  palmatEe.  The  mucosa 
itself  contains  numerous  mucous  glands,  which  vary  from  small  crypts 
to  those  suggesting  the  racemose  type.  The  entrance  to  many  of 
even  the  large  glands  is  very  small  (the  flask-Uke  glands),  whereas 
others  are  tubular  in  character  or  undergo  repeated  branching — all 
points  that  favor  the  continuance  of  the  infection.  The  cervical  glands 
are  the  lurking-place  of  the  gonococcus,  and,  owing  to  their  nature, 
offer  peculiar  protection  against  the  ordinary  forms  of  treatment. 
As  the  result  of  gonorrhea,  the  entire  mucosa  becomes  edematous, 
infiltrated  with  inflammatory  products,  and  the  openings  of  the  glands 
become  even  more  contracted.  As  the  infection  becomes  subacute 
or  chronic,  the  stroma  of  the  mucosa  in  many  areas  assumes  more  or  * 
less  its  normal  appearance,  the  inflammation  usually  persisting  as  a 
periglandular  reaction,  characterized  by  an  infiltration  of  small  round- 
cells.  Not  infrequently  a  narrow  zone  of  small  round-cells,  occasion- 
ally leukocytes,  free  blood,  serum,  and  engorged  or  newly  formed 
vessels,  is  present  immediately  beneath  the  squamous  epithelium  about 
the  external  os.  As  a  result  of  inflammation  some  of  the  gland-open- 
ings become  occluded,  and  small  retention  cysts  (ovula  Nabothi)  occur. 
These  are  lined  by  cylindric  epitheUum,  which  in  many  cases,  owing  to 
infraglandular  pressure,  is  greatly  flattened.  The  cylindric  epithelium 
of  the  canal  not  infrequently  shows  metaplastic  changes,  and  even 
areas  of  reduplicated  layers  of  more  or  less  typical  squamous  epithe- 
lium may  be  observed.  Metaplasia  of  the  surface  epithelium  is  more 
frequent  than  that  of  the  glandular.  A  certain  amount  of  cervical  hy- 
pertrophy usually  results  from  long-standing  inflammation.  The  in- 
flammation is,  as  a  rule,  moderately  superficial. 

CORPOREAL  ENDOMETRITIS  AND  METRITIS 
These  conditions  invariably  result  from  an  endocervicitis.  The 
extension  from  the  mucosa  of  the  cervix  to  that  of  the  body  of  the 
uterus  occurs  with  but  few  exceptions  either  at  a  menstrual  period  or 
shortly  following  the  emptying  of  a  pregnant  uterus.  While  gonorrheal 
endocervicitis  tends  to  become  chronic  and  exhibits  Uttle  or  no  dis- 
position to  spontaneous  cure,  gonorrhea  of  the  corporeal  endometrium 
in  many  cases  does  go  on  to  resolution.  This  may  possibly  be  ac- 
counted for  by  the  excellent  blood-supply  and  drainage  of  this  locahty. 
Not  infrequently  an  active  inflammation  of  the  endometrium  is  kept  | 
up  by  a  constant  reinfection  from  the  leaking  uterine  end  of  a  pyosal- 


I 


^%^ 


■\  ^^ 


Fig.  3. — Endometrium  During  the  Postmenstrual  Period. 
The  glands  run  a  straight  course,  perpendicular  to  the  surface.     The  lumen  of  each  gland  is  extremely 
and  empty  (C.  C.  Norris  and  F.  E.  Keene,  Surg,.  Gyn.,  and  Obst.,  January.  1909,  pp.  44-54). 


J 


Ur 


kl/i 


'"■.f"". 


Fig.  4. — Endometrium  Dukino  the  Intekval. 
Tin-  upper  portion  of  the  stroma  shows  odcmu.     The  luminu  of  the  gland.'*  nn;  tlUtinrtlv  wider  thiin  lit 
thr  prcceditiK  rttuge.  und  have  aaaumed  the  corlwcrew  shape.     Some  of  the  glaticU  contain  u  thready  sub- 
stance, taking  the  cosin  stain  (C.  C.   NorrU  and  F.  E.  Keene,  Surg.,  Gyn.,  and  Obst.,  January,    1009.  pp. 
44-o4). 


Fig.  5. — Endometrium  During  the  Premenstrual  Stage. 
The  superficial  compact  and  deep  spongy  layers  are  easily  recognized.  The  glands  ar 
and  their  lumina  are  still  wider  than  those  of  the  interval.     Many  of  the  glands  contain  i 
and  F.  E.  Keene,  Surg.,  Gyn.,  and  Obst.,  January,  1909,  pp.  44-54). 


irregular  in  shape 
lucus  (C.  C.  Norris 


I 


PATHOLOGIC    CHANGES    PRODUCED    BY   THE    GONOCOCCUS  99 

pinx.  Indeed,  well-marked  cases  of  chronic  corporeal  endometritis 
are  comparatively  seldom  observed,  except  in  conjunction  with  tubal 
infection  or  abortion,  and  even  in  the  presence  of  well-marked  ad- 
nexal  lesions  the  endometrium  is  often  comparatively  normal.  Prior 
to  the  researches  of  Adler  and  Hitschmann,'  which  were  subsequently 
confirmed  by  the  work  of  Keene  and  the  author,-  as  w'ell  as  by  other 
observers,  many  of  the  physiologic  changes  incident  to  the  normal 
menstrual  cj^cle  were  viewed  as  pathologic,  and,  as  a  result,  endome- 
tritis was  frequently  diagnosed  when  no  inflammatory  change  of  any 
sort  existed.  Furthermore,  the  classification  of  endometritis  was 
greatly  compUcated  by  such  qualifying  terms  as  glandular,  interstitial, 
polypoid,  fungoid,  etc.,  which  were  in  manj^  instances,  at  least,  merely 
phases  of  the  menstrual  cycle.  Thus,  if  the  endometrium  to  be  ex- 
amined has  been  removed  a  few  days  prior  to  menstruation,  the  glands 
would  naturally  be  large  and  prominent,  and  a  glandular  endometritis 
would  be  diagnosed,  whereas  if  the  tissue  chanced  to  be  examined  in 
the  postmenstrual  period,  it  was  often  thought  to  be  the  seat  of  an 
interstitial  inflammation. 

Albrecht^  divides  endometritis  into  three  forms — acute,  chronic, 
and  specific  (syphilitic  and  tubercular).  The  author  has  found  this 
classification  entirely  satisfactory.  This  question  is  not,  however, 
entirely  settled.  Hitschmann  and  Adler"*  believe  that  there  may  be  a 
glandular  hyperplasia,  but  that  it  has  nothing  to  do  with  inflammation, 
and  that  the  term  "endometritis  glandularis  hyperplastica "  is  a  mis- 
nomer. They  assert  that,  even  in  the  early  stages  of  inflammation, 
a  diagnosis  of  endometritis  is  justifiable  onlj''  when  the  plasma  cell  is 
present.  Buttner''  considers  the  plasma  cell  a  certain  criterion  of 
inflammation  and  that  nothing  else  is  so  positive.  He,  however,  be- 
lieves an  abundant  infiltration  of  leukocytes  may  be  accorded  con- 
siderable importance.  Mittelmann,'''  while  conducting  a  research  sug- 
gested by  Veit,  came  to  the  conclusion  that  there  may  be  an  acute 
or  a  subacute  endometritis  in  which  no  plasma  cells  are  present,  but 
that  in  chronic  endometritis  these  cells  can  alwaj^s  be  observed.  This 
observer  concludes  that  the  diagnosis  of  endometritis  depends  upon 
the  microscopic  finding,  and  cannot  be  made  from  the  cUnical  symp- 
toms.    Other  authors  claim  that  the  presence  or  absence  of  the  plasma 

'  Adler  and  Hitschmann:   Monats.  f.  Geb.  u.  Gyn.,  vol.  xxvii,  No.  1. 

'  Norris,  C  C,  and  Keeno,  F.  10.:  Surg.,  Gyn.,  and  Obst.,  January,  1909,  p.  44. 

'  Albrechl:  Monats.  f.  G(>b.  u.  Gyn.,  1911,  vol.  xxxiv,  p.  397. 

•  Hitschmann  and  Adler:  Miinch.  mod.  Woch.,  1909,  No.  41,  p.  2130. 
»  Buttner:  Miinch.  mod.  Woch.,  1909,  No.  30,  p.  10,')2. 

•  Mittelmann,  C:   Miinch.  med.  Woch.,  1910,  No.  14,  p.  703. 


100  GONORRHEA    IN   WOMEN 

cell  is  of  little  significance.  Albrecht'  declares  that  in  the  examination 
of  130  specimens  of  curetings  and  the  endometrium  of  15  cases  in 
which  the  uterus  had  been  removed,  in  only  5  per  cent,  were  plasma 
cells  found. 

It  is  certain  that  the  physiologic  changes  incident  to  menstruation 
continue,  sometimes  more  or  less  modified,  in  cases  of  endometritis. 
It  is  also  certain  that  some  cases  of  endometritis  exhibit  a  tendency 
toward  the  so-called  glandular  form,  whereas  in  others  the  glands  are 
contracted  and  the  stroma  is  condensed  entirely  apart  from  the 
changes  incident  to  menstruation.  These  facts,  while  admitted  by 
Mittelmann,=  are  explained  by  her  on  the  ground  of  a  preexisting  hy- 
perplasia or  atrophy.  Ellerbroeck,'  however,  after  examining  the  en- 
dometrium of  110  cases  of  actual  endometritis,  in  all  of  which  the  acute 
attack  had  subsided  prior  to  the  removal  of  the  endometrium,  concludes 
that  Hitschmann  and  Adler  are  in  error  when  they  deny  absolutely  the 
existence  of  a  glandular  form  of  endometritis.  Frank"  also  states  that 
glandular  hypertrophy  and  hyperplasia  may  be  due  to  inflammation, 
as  well  as  to  ovarian  influence.  The  author's  experience  is  that  glan- 
dular, and  more  particularly  interstitial,  changes  of  sufficiently  pro- 
nounced characteristics  to  warrant  a  diagnosis  do  occur  as  the  result 
of  inflammation,  and  that  while  it  has  nearly  always  been  possible  to 
demonstrate  the  plasma  cell  in  both  acute  and  chronic  cases,  he  con- 
siders it  of  great  diagnostic  value,  but  is  of  the  opinion  that  its  presence 
is  not  essential , for  the  diagnosis  of  endometritis.  While  the  presence 
or  absence  of  the  plasma  cell  is  a  valuable  aid  to  the  diagnosis  of  en- 
dometritis, the  entire  question  should  not,  however,  rest  upon  this 
point.  To  demonstrate  the  presence  of  plasma  cells  certain  special 
fixing  and  staining  reagents  are  necessary.  As  a  further  proof  that 
the  glandular  and  interstitial  changes  are  not  entirely  dependent  upon 
the  menstrual  cycle,  it  may  be  stated  that  it  is  no  uncommon  experi- 
ence to  find,  in  the  same  endometrium,  some  areas  presenting  pro- 
nounced glandular  hypertrophies,  whereas  in  others  atrophic  or  in- 
terstitial changes  may  be  observed.  However,  in  many  cases  no 
inflammatory  glandular  changes  are  present,  and,  indeed,  only  rarely 
are  these  sufficiently  well  marked  to  merit  the  term  glandular  or  inter- 
stitial endometritis.  This  is  an  additional  argument  against  the  em- 
ployment of  the  terms  glandular,  interstitial,  polypoid,  etc.,  when  re- 
ferring to  inflammations  of  the  endometrium. 

'  Albrecht,  H.:  Munch,  med.  Woch.,  1910,  No.  23,  p.  1260. 
'  Mittelmann,  C:   Mtinch.  med.  Woch.,  1910,  No.  14,  p.  763. 
'Ellerbroeck:  Zentralbl.  f.  Gyn.,  1909,  vol.  .\xxiii,  p.  682. 
*  Frank,  R.  T.:  Amer.  Jour.  Obst.,  February,  1912,  p.  207. 


I 


fili^*^tt. 


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■0:.. 


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>  C 


Via.  0.— The  Decidda  or  In 
H,  Hpoiigy  layer;    C,  iruisclt'  (C.  C.  li>^iii.i  mn 
uiiry,  )!)()9,  pp.  44-51). 


nml  F.  E.  Kceiio.  tSurg.,  Gyn,.  aiicl  I  II>mI., 


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Fig.    7. — Glandular     Epithelium     During 

THE    POSTMENSTRUAL    StaGE. 

The  cells  are  low  and  narrow,  and  the 
nucleus  occupies  a  large  portion  of  the  cell. 
The  lumen  of  the  gland  is  very  narrow  and 
completely  empty  (C.  C.  Norris  and  F.  E. 
Keene.  Surg.,  Gyn.,  and  Obst.,  January.  1909, 
pp.  44-54). 


Fig.  8.— Glan-dular  Epithelium  During  the  In- 
terval. 
The  cells  have  become  higher  and  broader,  and  at 
.1  -^how  an  inner  granular  and  outer  homogeneous  zone. 
The  nuclei  are  well  stained  and  are  situated  at  the  base 
of  the  cells.  The  lumen  of  the  gland  is  dilated  and 
contains  a  thready  material  (C.  C.  Norris  and  F.  E. 
Keene.  Surg.,  Gyn..  and  Obst.,  January,  1909). 


%. 


c 


Fiti.  '.I.— Glaxdi-lar  EpiTHEi.nr.M  Dvri.ng  the   Latk  Premenstrual  Stage. 
The  individual  cells  are  indistinctly  differentiated  from  one  another.       The  cells  have  become  much 
broader,  and  their  inner  contour  irregular.     In  some  areas  (.4)  the  inner  aspect  of  the  cells  appears  broken, 
with  discharge  of  their  contents  into  the  lumen  of  the  gland.     .\t  B  there  has  been  a  proliferation  of  the  cells; 
C.  mucus  (C.  C.  Norris  and  F.  E.  Keene,  Surg.,  Gyn.,  and  Obst.,  .lanuary,  1909). 


PATHOLOGIC    CHANGES    PRODUCED    BY    THE    GONOCOCCUS  101 

Since  the  plasma  cell  is  now  recognized  not  only  as  an  indication  of 
endometritis,  but  is  by  some  authorities  considered  to  be  of  much 
significance  in  the  differential  diagnosis  between  gonorrhea  and  other 
forms  of  infection,  not  only  in  the  endometrium,  but  also  in  the  adnexa, 
a  more  detailed  description  may  not  be  out  of  order. 

By  Mallory's  eqsin-methylene-blue  stain  the  lymphogenous  cells 
maj'  be  demonstrated  particularly  well,  and  their  identification,  even 
with  the  low  power,  is  easy.  By  Schridde's'  method  of  osmic  acid  and 
acid  fuchsin  stain,  certain  granular  elements  in  the  protoplasm  sur- 
rounding the  nucleus  can  be  beautifully  shown,  not  only  in  the  plasma 
cell,  but  also  in  the  lymphocytes  and  Ij'mphoblasts.  Unna-Pappen- 
heim's  methyl-green  stain  also  gives  excellent  results. 

Schridde's  method  for  staining  cells  is  as  follows: 

1.  Within  a  few  minutes  of  removal  place  tissue  in  Orth's  fluid,  warmed 
to  35°  C,  and  keep  in  the  incubator  at  this  temperature  for  twenty-four  hours. 

2.  Miiller's  fluid  at  room  temperature,  twenty-four  hours. 

3.  Running  water,  twenty-four  hours. 

4.  Distilled  water  (many  changes),  six  hours. 

5.  One  per  cent,  aqueous  solution  of  osmic  acid,  in  the  dark,  twentj^- 
four  hours. 

6.  Place  sections  in  ascending  alcohols  (70  per  cent.,  80  per  cent.,  95 
per  cent.,  and  absolute),  allowing  them  to  remain  in  each  for  about  twelve 
hours. 

7.  Chloroform  (pure),  four  hours. 

8.  Equal  parts  of  chloroform  and  ])araffin  (55°  F.)  over  tlic  oven, 
twelve  hours. 

9.  Paraffin  (.50°  to  55°  F.)  liaths,  in  the  oven  (two  changes),  two  hovu's 
each. 

10.  limbed  (60  paraffin)  and  cool  quickly  in  cold  water. 

11.  Cut  thin  sections  (1  to  2 /i). 

Staining  is  as  follows: 

1.  Place  sections  in  xylol  (two  changes),  five  minutes  each. 

2.  Absolute  alcohol,  95  per  cent.,  and  SO  per  cent.,  three  minutes  each. 

3.  Wash  in  distilled  water. 

4.  Stain  in  warmed  anilin-water  acid-fuclisin  (acid-fuciisin,  20  grams; 
anilin-water,  100  c.c.)  over  night  or  from  two  to  twenty-four  hours. 

5.  Drain  off  and  differentiate  in  the  fullowing  solution: 

Saturated  alcoholic  solution  of  picric  acid I  jiarl 

Twenty  per  cent,  alcohdl 7  p.arts 

until  the  section  lieccjnies  a  clear,  yellowisli-red  color,  wliicli  will  lake  about 
thirty  minutes  or  a  little  longer. 

'  Siliiiilric:   MiiMch.  incfl.  Wocli.,  KKIS,  No.  •.'(), 


102  GONORRHEA    IN    WOMEN 

6.  Dehydrate  in  95  per  cent,  alcohol;  then  in  absolute  for  a  few  seconds, 
clear  in  xj'lol  and  mount  in  xylol  balsam. 

Result:  Neutrophihc  granules,  brownish  red;  eosinophilic,  blackish  red; 
plasma-cell  granules,  brick  red;  mast-cell  granules,  grayish  black;  basophilic 
granules,  unstained,  but  easily  distinguishable;  bro^aiish-red  granules  in  the 
lymphocytes. 

The  plasma  cell  is  about  twice  the  size  of  a  lymphoid  cell,  and  pos- 
sesses a  comparatively  large  amount  of  basophilic  protoplasm.  The 
cell  outline  is  usually  polyhedral  and  generally  irregular,  and  often 
shows  a  pale  staining  area  surrounding  the  nucleus.  The  nucleus  is 
moderate  in  size,  and,  owing  to  the  large  amount  of  chromatin  pres- 
ent, stains  deeply.  It  usually  presents  a  circular  or  wheel-like  ap- 
pearance. Gurd^  has  drawn  attention  to  the  curious  appearance  of 
the  nucleus  observed  in  some  sections ;  the  appearance  does  not  in  the 
least  resemble  the  typical  "Radkern,"  but  shows  two  narrow,  crescent- 
shaped  masses  of  chromatin  upon  each  of  the  two  sides  of  the  nucleus, 
as  if  the  chromatin  had  arranged  itself  entirely  over  the  surface  of  the 
nucleus,  leaving  no  meshwork  of  chromatin  material  within  the  latter's 
substance.  The  origin  of  the  plasma  cell  is  still  somewhat  in  doubt. 
Unna-  believed  that  the  cell  developed  directly  from  fibrous  tissue. 
Marchand^  suggested  that  it  might  be  derived  from  specially  differen- 
tiated adventitia  cells.  Joannovics^  asserts  that  he  believes  that  the 
plasma  cell  is  a  derivative  of  the  tissue  lymphocyte,  which,  for  the 
most  part,  is  developed  from  adventitial  elements.  Marschalko^  and 
Gurd"  believe  the  cell  to  be  developed  from  the  lymphocyte  of  the 
blood  or  lymph,  and  this  opinion  is  generally  held  by  pathologists  at 
the  present  day.  Schridde^  states  that  large  numbers  of  Russel's 
bodies  are  always  found  among  plasma  cells.  Gurd,*  on  the  other 
hand,  declares  that  in  his  preparations  they  were  not  more  numerous 
than  in  general  chronic  inflammations.  Miller'  has  carefully  studied 
these  structures,  and  concludes  that  true  Russel's  bodies  develop  only 
in  plasma  cells;  that  when  they  are  extracellular,  they  are  round, 
refractile,  and  stain  an  intense  black  with  Weigert's  stain,  and  that  he 
believes  them  to  be  a  myelin  degeneration  of  the  protoplasm  of  the 

'  Gurd,  F.  B.:  Jour.  Med.  Research,  1910,  vol.  xxiii;  new  series,  vol.  x\'iii,  p.  169. 
'  Unna:   Plasmazellen,  Eneyklopaedie  der  mik.  Technik,  1903,  p.  1116. 
'  Marchand:   Der  Prozess  der  Wundheilung,  mit  Einfluss  der  Transplantation,  Stutt- 
gart, 1910. 

*  Joannovics:  Cent.  f.  all.  Path.  u.  path.  Anat.,  1909,  vol.  xx,  p.  1011. 

'  Marschalko:  Arch.  f.  Dermat.  u.  Syph.,  1895,  vol.  xxx,  p.  214. 

'  Gurd,  E.  B.:  Jour.  Med.  Research,  1910,  vol.  xxiii;  new  series,  vol.  xviii,  p.  169. 

'  Schridde:  Munch,  med.  Woch.,  1908,  No.  20. 

'  Gurd,  F.  B.:  Jour.  Med.  Research,  1910,  vol.  xxiii;  new  scries,  vol.  xviii,  p.  171. 

'  Miller,  J.  W.:  Virchow's  Archiv,  1910,  vol.  199,  p.  482. 


■^;>^v 


4/'. 


Fig.  10. — Tyi'Ical  Opitz-Gkbhard  Glands,  Showing  Fern-like  Ingrowths  ok  Prouferatino  Epitheuum. 

Nole  that  the  general  character  of  this  gland  is  similar  to  that  of  the  premenstrual  stage,  only  in  this  case  the 

chanEcs  are  more  advanced  (C.  C.  \orris  and  F.  F..  Kccnc,  Surg.,  Gyn.,  and  Obst..  .January,  IflOD). 


/,. 


-[^vfc-": 


:f  I 

In;.    II.  — !<TR(1.«A    ('eL1.«. 

I,  .''Iroiiin  cells  in  poatmenstrual  stane.  2,  Stroma  cells  during  interval,  showing  colleclion  of  small 
round-cells.  ;j.  Stroma  cells  during  late  premenstrual  stage.  4,  Deciduu  cells  (C.  C.  Norris  and  F.  K.  Keene, 
Surg.,  Gyn.,  anil  Olist..  .lanunry,  lUOdi. 


PATHOLOGIC    CHANGES    PRODUCED    BY    THE    GONOCOCCUS  103 

plasma  cell.  Miller  does  not  believe  that  Russel's  bodies  result  from 
hyaline  degeneration,  and  warns  against  confounding  them  with 
vacuolated  degeneration  of  the  plasma  cell  nucleus,  or  with  colloid 
produced  by  epithelium. 

Gonorrheal  endometritis  cannot  positively  be  distinguished  either 
macroscopically  or  microscopically  from  manj'  other  forms  of  infec- 
tion of  this  locality,  except  by  the  demonstration  of  the  specific  micro- 
organism in  the  tissue  or  exudate.  This  is  usually  easj'  in  acute  cases, 
but  often  difficult  after  they  have  become  chronic.  During  the  acute 
stage  the  endometrium  is  thickened,  reddened,  edematous,  and  hy- 
peremic,  and  is  bathed  in  a  moderately  thin,  punalent  discharge. 
Areas  of  subepithelial  ecchymosis  are  often  observed,  and  it  frequently 
happens  that  the  entire  mucosa  is  not  equally  involved.  The  surface 
often  presents  a  granular  appearance.  During  the  chronic  stage  the 
mucosa  may  present  an  appearance  differing  but  little  from  that  of 
the  normal  endometrium.  It  is,  however,  usually  more  or  less  thick- 
ened, although  atrophic  changes  sometimes  follow  subsidence  of  an 
acute  process.  Occasionally  the  surface  presents  an  irregular,  poly- 
poid contour,  and  granular-like  areas  may  be  observed. 

Histology. — In  studying  the  endometrium  the  changes  incident  to 
the  normal  menstrual  cycle  must  always  be  borne  in  mind,  for  although 
the  normal  changes  may  be  modified  as  a  result  of  inflammation,  they 
should  by  no  means  be  overlooked.  Data  giving  the  date  of  the  last 
menstrual  period,  the  regularity  and  frequency  of  the  periods  should 
be  supphed  to  the  pathologist.  In  gonorrheal  endometritis  the  most 
marked  changes  are  usually  found  in  the  superficial  portions  of  the 
endometrium. 

Acute  endometritis  is  characterized  by  swelling,  edema,  and  hy- 
peremia of  the  mucosa.  The  surface  may  present  areas  of  granulation, 
whereas  in  other  parts  the  surface  epithelium  may  be  proliferated  and 
more  or  less  atypical  in  size,  shape,  and  staining  properties.  The 
glands  ma  J'  show  varying  changes;  in  some  cases  they  are  normal, 
whereas  in  others  they  are  enlarged  or  may  be  cystic.  In  some  in- 
stances, as  a  result  of  inflammatory  exudates  in  the  stroma,  the  glands 
may  appear  to  be  contracted.  The  glandular  epitheUum  is  rarely 
proliferated  or  desquamated,  but  usually  shows  evidences  of  a  well- 
marked  inflammatory  reaction.  The  stroma  is  infiltrated  with  serum 
and  polymorphonuclear  leukocytes,  and  often  contains  free  blood. 
The  stroma  cells  are  edematous,  and  may  stain  irregularly  or  imper- 
fectly. The  blood-vessels  are  congested.  Generally  the  myometrium, 
for  a  greater  or  less  dejjth  immediately  luulerlying  the  mucosa,  is  in- 
filtrated with  acute  inflammatory  products.     The  areas  of  infiltration 


104  GONORRHEA    IN    WOMEN 

are  often  observed  surrounding  a  blood-  or  a  lymph-vessel,  and  follow- 
ing the  course  of  the  latter  through  the  myometrium  for  some  distance. 

Chronic  Endometritis. — During  the  chronic  stage  the  most  marked 
pathology  is  usually  found  in  the  superficial  portion  of  the  endome- 
trium. The  surface  epithelium  is  flattened,  and  in  some  areas  may  be 
desquamated,  whereas  in  others  proliferation  and  even  metaplasia  to 
cells  resembling  squamous  epithelium  may  be  present.  Runge^  has 
called  attention  to  the  fact  that  in  some  cases  of  endometritis  the  cil- 
iated borders  of  the  surface-cells  appear  to  be  more  robust  and  resist- 
ant than  in  the  normal  endometrium,  and  may  be  recognized  in  alco- 
holic preparations.  Hurdon-  has  suggested  that  these  metaplastic 
changes  are  possibly  analogous  to  leukokeratosis  of  the  vulvar  mucosa. 
The  glands  are  often  enlarged  in  their  deeper  portions,  and  in  some  in- 
stances, due  to  occlusion  or  constriction  near  the  surface,  may  be  cys- 
tic. Owing  to  the  presence  of  inflammatory  exudates  in  the  stroma, 
the  glands  may  be  somewhat  irregularly  arranged,  some  being  close 
together,  whereas  others  are  widely  separated.  The  glandular  epi- 
thelium presents  changes  similar  to  those  found  in  the  surface-cells, 
but  these  are,  as  a  rule,  less  pronounced.  The  gland  lumina  may  be 
empty  or  may  contain  serum,  leukocytes,  blood,  or  epithelial  debris. 
Adler  and  Hitschmann^  assert  that  in  the  normal  endometrium  mucus 
is  not  present  in  the  corporeal  endometrium  during  the  post-menstrual 
or  interval  periods ;  when  the  endometrium  is  the  seat  of  an  infection, 
mucus  is  not  infrequently  observed  in  the  glands,  and  may  be  present 
at  any  time,  although  it  is  more  frequently  observed  during  the  pre- 
menstrual and  early  menstrual  periods.  In  chronic  endometritis  the 
stroma  is  more  or  less  densely  infiltrated  with  inflammatory  products, 
and  with  proper  fixing  and  staining  conditions,  plasma  cells  can  usually 
be  demonstrated.  The  blood-vessels,  which  normally  consist  only  of 
endothelial  tubes,  are  often  found  to  possess  well-developed  muscu- 
lar walls,  and  may  be  increased  in  number.  The  underlying  uterine 
muscle  is  usually  more  or  less  involved  in  the  inflammatory  process. 

Metritis. — In  gonorrheal  infections  of  the  uterus  the  inflammation 
may  be  limited  to  the  mucosa  or  may  involve  the  underlying  myo- 
metrium. In  severe  cases  the  uterine  parenchyma,  especially  the  inner 
layer,  is  always  invaded.  In  the  acute  stage  the  uterus  is  enlarged, 
softened,  and  boggy.  The  normal  shape  is  usually  quite  well  pre- 
served, although  a  tendency  toward  broadening  of  the  organ  is  gen- 

'  Winter,  G.,  and  Runge;  Text-book  of  Gynecological  Pathology,  edited  by  J.  G.  Clark, 
Philadelphia  and  London. 

'Hurdon,  E.,  Kelly,  H.  A.,  and  Noble,  C.  P.:  Gynecology  and  Abdominal  Surgery, 
Philadelphia  and  London,  1907,  vol.  i,  p.  11.5. 

^  Adler  and  Hit.srhmann:  Monat.s.  f.  Geb.  u.  Gyn.,  vol.  xxvii.  No.  1. 


FlO.     12.— HVPKUTROPHy    of    the    CeHVIX,    CllUONie     KxiJOMCTliniS,     ChHOXIC     MeTHITI.-.     and     HlLATERAL 

Adnkxitis. 
The  utonis  is  enlarged,  this  being  especially  noticeable  in  its  lateral  diameters.  The  uterine  walls  are 
thickened,  and  the  musculature  appears  somewhat  coarser  than  normal.  Here  and  there,  projecting  from  the 
cut  surface  of  the  musculature,  prominent  blood-vessels  are  observed.  The  endometrial  cavity  is  normal  in 
shape,  and  the  mucoso  is  but  little  thickened.  The  arbor  vitte  of  the  cervical  canal  are  unusually  prominent, 
and  in  the  fresh  specimen  were  considerably  reddened.  The  tubes  have  been  converted  into  small  pyosnlpinges. 
The  ovaries  are  enlarged  and  contain  retention  cysts.  On  microscopic  examination  they  were  founil  to  jiresenl 
»  well-marked  peripheral  inflammation  and  some  thickening  of  the  capsule. 


Sj.*^»«rtr-=^?-^:,CT.^ 


is? 


I'lc.  1^. — Kndomkticitih  and  Mkthitim. 
Th."  .•ri.|..nu-trium  is  uboiit  normiil  in  thickncMH.  TIk-  Murfiirr 
cpitht-liuiii  in  iiiiK-h  fluttriied.  Tin-  Klands  arc  noniuil  in  mimbrr  iiiu) 
of  the  intorvul  type.  Tlic  Klnndular  (■pitheliiim  also  m1iou'»  dt'KeniTntivo 
chanK('».  but  these  arc  Ic(*h  innrki-d  than  on  the  surface.  The  stroma 
is  infiltrated  with  inflammatory  products,  chieHy  plasma  colls.  The 
underlying  musculature  also  tukes  part  in  the  inflammatory  reaction. 
This  is  moat  nnirked  in  the  sonc  inunedialely  vinderlyins  the  endo- 
metrium, and  in  many  areas  appears  to  follow  the  course  of  the  blood- 
vessels or  lymphatics,  Ilyslereetomy  was  performed  about  ten  days 
after  a  m.-tistrual  periotl  had  occurred  (  X   10). 


PATHOLOGIC    CHAXGES    PRODUCED    BY    THE    GONOCOCCUS  105 

erally  seen.  In  the  chronic  stage  the  softening  is  less  marked,  Init 
there  is  nearly  always  some  enlargement,  especially  in  the  trans\'erse 
diameters.  Pronounced  cases  of  gonorrheal  metritis  are  usually 
associated  with  adnexitis  and  its  accompanying  evidences  of  pelvic 
peritonitis. 

GONORRHEA  OF  THE  FALLOPIAN  TUBES 
The  gonorrheal  inflammation  extends  from  the  endometrium  to 
the  Fallopian  tube  by  direct  continuity  along  the  mucosa.  At  first 
only  the  mucosa  of  the  tube  is  involved,  but  as  the  disease  progresses 
the  muscularis  and  even  the  serosa  are  affected,  and  various  lesions, 
such  as  salpingitis,  pyosalpinx,  hydrosalpinx,  tubo-ovarian  abscess, 
or  tubo-ovarian  cysts,  may  be  produced.  With  these  are  associated 
the  usual  lesions  of  pelvic  peritonitis.  At  times  a  suppurative  lesion 
will  be  present  in  one  adnexa,  whereas  the  other  may  be  the  seat  of  a 
hydrosalpinx  or  a  perisalpingitis,  or  the  tube  and  ovary  may  be 
normal;  in  still  other  cases  bilateral  pathology  may  be  present.  No 
rule  can  be  laid  down  in  this  respect,  except  that  the  more  frequent, 
prolonged,  and  severe  the  attacks  of  pelvic  peritonitis  have  been,  the 
more  extensive  are  the  lesions  likely  to  be. 

The  most  frequent  pathologic  condition  produced  by  a  gonorrheal 
infection  of  the  tube  is  a  pyosalpinx.  Among  1070  inflannnatory  lesions 
of  the  tubes  seen  in  the  Laboratory  of  Gynecologic  Pathology  at  tlie 
University  of  Pennsylvania,  none  of  which  was  associated  with  neo- 
plasms, there  were  425  pus-tubes,  151  cases  of  salpingitis,  253  hydro- 
salpinges,  184  cases  of  perisalpingitis,  38  tubo-ovarian  abscesses,  and 
19  tubo-ovarian  cysts. 

Gonorrheal  lesions  of  the  Fallopian  tubes  possess  certain  character- 
istics that,  while  not  sufficient  absolutely  to  prove  the  etiology  of  the 
infection,  are  pronounced  enough  in  the  great  majority  of  cases  to 
enable  the  skilled  pathologist  to  be  moderately  certain  of  the  type  of 
infection  present.  The  fact,  as  before  mentioned,  that  the  gonococcus 
invades  the  tub(>s  by  means  of  continuity  of  the  surface  mucosa  from 
the  uterus,  produces  certain  macroscopic  or  microscopic  pictures  that 
are  more  or  less  characteristic.  Pyogenic  microorganisms,  such  as  the 
streptococcus  and  the  staphylococcus,  reach  the  tubes  by  way  of  either 
the  blood-  or  the  lymph-vessels  of  the  broad  ligament,  the  mucosa  not 
being  primarily  invaded.  In  these  infections  ovarian  abscesses  and 
cellulitis  are,  therefore,  common,  while,  from  the  very  nature  of  thc^ 
gonococcal  invasion,  these  structures  are  less  frequently  involved,  and 
such  lesions  are  generally,  if  not  always,  secondary  to  salpingitis. 
Tuberculosis,  which  constitutes  from  8  to  10  per  cent,  of  all  inflaMuua- 


106  GONORRHEA    IN   WOMEN 

tory  tubal  lesions,  is  not  infrequently  secondary  to  tuberculosis  in 
other  parts  of  the  body,  and  even  when  primary,  usually  produces 
a  characteristic  pathology.  Small  mihary  tubercles  scattered  over 
the  surface  of  the  tube  and  a  tendency  toward  imperfect  closure  of  the 
abdominal  ostium  or  the  visibility  of  fimbrise  after  closure  of  the  outer 
end  of  the  tube  and  cheesy  contents  are  almost  positive  proof  of  the 
nature  of  the  infection.  The  frequency  with  which  the  abdominal 
ostium  is  not  completely  closed  in  tuberculous  cases  is  most  striking, 
and  may,  in  fact,  be  said  to  be  almost  characteristic  of  this  variety  of 
infection.  Even  when  apparently  closed,  the  appearance  of  fimbrise 
on  the  distal  end  of  the  tube  is  most  suggestive,  and  is  an  important 
diagnostic  aid  even  before  the  removal  of  these  organs.  An  absolute 
diagnosis  of  tuberculosis  can  almost  invariably  be  made  with  the  aid 
of  the  microscope.  Tubal  infections  secondary  to  peritonitis,  appendi- 
citis, or  general  peritoneal  conditions  affect  primarily  the  outer  coats 
of  the  tube,  and,  as  a  result,  the  mucosa  is  often  found  to  be  compara- 
tively free  from  inflammation. 

Some  authors  (Pellagatti,  Posner,  and  Joseph^  consider  the  pres- 
ence of  eosinophiles  important  in  the  diagnosis  of  gonorrhea,  especially  if 
they  also  appear  early  in  the  urethral  discharge.  Taylor,-  by  his  own 
work  and  by  that  of  others,  has  shown  that  these  cells  are  of  little  value 
in  the  determination  of  the  type  of  the  infection.  Von  Rosthorn,' 
Arthmann,^  and  Wertheim*  declare  that  it  is  impossible  to  differen- 
tiate gonococcal  from  other  acute  tubal  infections.  ZweifeP  writes 
that  in  gonorrheal  infection  the  tubal  epithelium  is  devoid  of  cilia  and 
is  sometimes  vacuolated,  a  condition  that  is  rarely  present  in  septic 
infections.  In  1907,^  and  again  in  1908,  Schridde*  directed  attention  to 
certain  histologic  peculiarities  of  the  Fallopian  tube  attacked  by  the 
gonococcus.  In  the  year  following  Amersbach^  published  a  paper  from 
AschofT's  laboratory  in  which  he  stated  that  when  the  plica  of  the  tube 
showed  swelling  and  a  profuse  infiltration  with  plasma  cells,  lympho- 
cytes, and  lymphoblasts;  when  the  cellular  infiltration  of  the  muscularis 
was  composed  chiefly  of  small  round-cells,  and  when  not  only  lymphoid, 
but  plasma  cells  and  lymphoblasts  were  present  in  the  purulent  con- 

'  Pellagatti,  Posner,  and  Joseph:  Quoted  by  Gurd:  Jour.  Med.  Research,  1910,  vol. 
xxiii;  new  series,  vol.  xviii,  p.  171. 

''  Taylor:  Jour.  Amer.  Med.  Assoc,  1907,  vol.  xUx,  p.  1830. 

'  Von  Rosthorn:  Arch.  f.  Gyn.,  1890,  vol.  xxxvii,  p.  337. 

*  Arthmann:  Virchow's  Archiv,  1887,  vol.  cviii,  p.  165. 

'  Wertheim:  Arch,  f.  Gyn.,  1892,  vol.  xlii,  p.  1. 

«  Zweifel:  Arch.  f.  Gyn.,  1891,  vol.  xxxix,  p.  353. 

'  Schridde:  Folia  Ifematologica,  1907,  vol.  iv,  p.  608. 

'  Schridde:  Deutsch.  med.  Woch.,  1908,  vol.  xxviii,  p.  1251. 

'  Amensbach:  Ziegler's  Beitriige  f.  all.  Path.,  1909,  vol.  xlv,  p.  341. 


Fio.  14. — Uterus  and  Adnexa  from  a  Case  of  Pelvic  Inflammatory  Disease  (actual  size). 
The  uterus  is  normal  in  size.  Its  anterior  surface  presents  a  few  adhesions.  The  tubes  have  become  con- 
verted into  pyosalpinges,  and  are  densely  adherent  to  the  underlying  ovaries.  The  left  adnexa  are  adherent 
to  the  posterior  and  superior  aspects  of  the  uterus,  and  merge  with  the  tube  and  ovary  of  the  ri(thtside,  forming 
an  inflammatory  mass,  the  individual  constituents  of  which  were  indistinRuishable  b<'fore  operation.  For  six 
weeks  prior  to  operation  this  case  received  palliative  treatment.  When  first  observed,  theadnexal  lesions  were 
at  least  twice  their  present  proportions. 


PATHOLOGIC    CHANGES    PRODUCED    BY   THE    GONOCOCCUS  107 

tents  of  the  tube,  the  diagnosis  of  gonorrhea  could  be  made  with  a 
reasonable  degree  of  certainty.  These  conclusions  were  based  upon  a 
studj'  of  75  cases,  34  of  which  he  considered  to  be  of  gonorrheal  origin. 
In  only  7  cases  were  gonococci  actually  identified.  Miller,'  on  the 
other  hand,  considers  that  the  plasma  cell  is  by  no  means  characteris- 
tic of  gonorrhea.  Gurd,'  in  an  excellent  paper  on  this  subject,  states 
that  although  it  is  impossible  to  speak  definitely  of  a  distinctive  his- 
tologic picture  of  gonorrheal  salpingitis,  the  great  preponderance  of 
plasma  cells  over  other  inflammatory  cells,  as  well  as  the  localization 
of  the  lesion  chiefly  in  the  mucosa  and  submucosa,  is  very  suggestive 
of  the  gonorrheal  origin  of  the  infection.  Gurd's  results  are  drawn 
from  a  carefullj"  studied  series  of  20  cases,  in  6  of  which  the  gonococcus 
was  isolated  in  culture,  and  although  in  5  additional  cases  the  gonococ- 
cus was  not  isolated,  this  organism  was  probably  the  original  exciting 
factor. 

Heymann^  has  investigated  50  cases  of  pyosalpinx  from  Veit's 
clinic,  with  a  view  to  determining  whether,  in  the  absence  of  bacterio- 
logic  proof,  the  histologic  appearance  can  be  regarded  as  a  sure  indi- 
cation, and  finds  that,  while  on  the  whole  his  conclusions  coincide  with 
those  of  Schridde,  he  does  not  regard  the  numerous  plasma  cells  as  in 
themselves  diagnostic,  but  considers  that  when  these  elements  are 
numerous,  arranged  in  groups  in  the  muscularis,  mucosa,  and  in  the 
pus  in  the  lumen ;  when  lymphocytes  are  numerous,  and  when  leukocytes 
are  few  or  entirely  absent,  and  when  there  is  a  broadening  out  of  the 
plica  and  an  agglutination  of  their  tips,  gonorrhea  is  almost  certainly 
the  exciting  cause.  Kronig,^  from  whose  clinic  Schridde  obtained  his 
material,  and  Aschoff^  support  Schridde's  views,  whereas  iNIenge," 
Walthard,"  and  Miller''  believe  that  the  histologic  picture  just  described 
is  not  peculiar  to  gonorrhea,  but  may  be  produced  by  any  chronic 
inflammation;  they  call  attention  to  the  fact  that  plasma  cells  are  by 
no  means  confined  to  the  genital  tract,  and  are  often  observed  in  other 
areas  from  which  gonorrhea  can  be  positively  excluded. 

Salpingitis. — During  the  acute  stage  the  tubes  become  elongated 
and  swollen.  As  a  general  rule,  the  normal  shape  of  the  tube  is  more 
or  less  preserved,  although  the  organ  is  often  kinked  and  bent  upon 
itself.  The  surface  is  congested  and  vascular,  and  adhesions  which  are 
readily  broken  up  are  nearly  always  present.     These  adhesions  are 

'  Miller,  J.  \V.:  Arch.  f.  Gyn.,  1909,  vol.  Ixxxviil,  p.  217;  also  Monals.  f.  CJel).  u.  Gyn., 
August,  1912,  p.  211. 

'(iuril,  v.  B.:  .Jour.  Med.  Research,  1910,  vol.  xxiii;  new  series,  vol.  xviil,  pp.  151-184 
'  Hoymann:  Zeit.  f.  Geb.  u.  Gyn.,  1912,  vol.  Ixx,  No.  3. 

•Kronig;  .Monats.  f.  Ocb.  u.  Gyn.,  AuKusl,  1912.  '  .\schoff:  Ihid. 

•Mongo:   Ihid.  'Walthard:   Ihid.  'Miller:   Ilnd. 


108  GONORRHEA    IN    WOMEN 

usually  more  numerous  on  the  distal  part  of  the  tube,  since  this  por- 
tion is  nearer  the  abdominal  ostium,  through  which  infectious  material 
is  often  being  extruded,  and  also  because  in  the  proximal  portion  of 
the  tube  the  walls  are  thicker  and  the  lumen  smaller,  containing  less 
mucosa  to  be  attacked.  On  section,  the  walls  of  the  tube  are  found  to 
be  soft,  congested,  and  edematous.  In  the  lumen  the  picture  varies 
according  to  the  portion  of  the  tube  examined.  The  mucous  folds  are 
reddened,  swollen,  and  bathed  in  a  purulent  or  seropurulent  exudate. 
If  the  disease  tends  to  become  chronic,  without  closure  of  the  external 
abdominal  ostium,  the  adhesions  on  the  surface  become  more  dense 
and  less  vascular.  The  tube  is  often  bent  upon  itself,  especially  in 
the  outer  half.  In  some  cases  the  tubes  are  but  little  enlarged,  but 
more  often  the  contrary  is  the  case.  At  this  stage  the  walls  are  mod- 
erately firm,  due  to  the  increase  in  fibrous  connective  tissue. 

Histology. — During  the  acute  period  the  greatest  inflammatory  re- 
action is  noted  in  the  mucosa,  and  in  the  earliest  stage  it  is  entirely  con- 
fined to  this  layer  of  the  tube — an  endosalpingitis.  During  the  chronic 
stage  there  is  always  more  or  less  involvement  of  the  muscularis.  The 
various  coats  of  the  tube  are  infiltrated  with  acute  or  chronic  inflam- 
matory products,  varying  with  the  stage  of  the  disease.  The  surface 
epithelium  presents  evidences  of  inflammation,  but  is  rarely  desqua- 
mated or  proliferated.  With  proper  staining,  large  numbers  of  plasma 
cells,  together  with  a  varying  number  of  Russel's  bodies,  can  be  de- 
tected. The  inflammatory  products  tend  to  extend  through  the  mus- 
cularis along  the  lymph-  and  blood-vessels,  and  groups  of  small  round- 
cells  or  polymorphonuclear  leukocytes,  according  to  the  stage  of  the 
infection,  are  seen.  In  cases  of  salpingitis  the  lumen  is  seldom  mark- 
edly dilated,  and  in  sections  prepared  in  the  ordinary  manner  it  rarely 
contains  much  pus.  In  rare  instances  a  specimen  will  be  seen  in  which 
the  distal  portion  of  the  tube  will  be  comparatively  normal,  or  may  be 
the  seat  of  a  moderate  degree  of  inflammation,  and  in  the  intramural 
portion  a  well-defined,  more  or  less  localized  abscess  is  present.  These 
abscesses  are  usually  not  large,  and  generally  drain  directly  into  the 
uterine  cavity.  The  etiology  of  this  condition  cannot  be  determined 
positively,  but  in  the  three  cases  seen  by  the  writer  the  suppuration 
appeared  in  a  tube  the  seat  of  an  old  salpingitis,  and  hence  the  sugges- 
tion is  offered,  and  indeed  it  was  practically  proved  in  one  specimen, 
that  during  a  previous  attack  ot  salpingitis  the  tube  lumen  was  occluded 
at  about  the  inner  end  of  the  isthmus,  and  that  a  reinfection,  perhaps 
with  more  virulent  microorganisms,  occurred  from  the  uterus,  which, 
owing  to  obliteration  of  the  lumen  at  this  point,  resulted  in  the  forma- 
tion of  an  abscess  localized  to  the  cornua  of  the  uterus.     Although 

I 


I  his  specimen  was  rt 
larged,  much  bent  upon  i 
fimbria  are  greatly  awolh- 


Fio.  Iti. — Acute  Gonokhhcal  SALi"i.\uiTi». 
■ci  durinK  the  early  stage  of  the  disease.     The  tube  is  somewhat  unifc 
and  presents  nurnerniis  adhesions.     The  abdominal  ostium  is  pjitulo 
everted.     On  niilkimr  tlic  riili.-.  pns  ould  he  expressed  thronpli  both  e 


^— .' •^^' 


,v* 


^PE- 


^^' lE 


tj. 


/i^!*' 


■\K 


.^\ 


.^> 


ef^^j=' 


% 


oil  f 


^^^ 


f?rc 


't 


V   \'iV 


.ijMitt.^     *<^-j4fei^-*»'^ 


Fig     17 — GONOKRHEAL   SALPI^GITIS 

The  section  has  been  taken  through  the  ampulla  of  the  tube  The  museularis  is  thin  and  contains  numer- 
ous areas  ot  inflammatory  infiltration.  The  mucous  folds  are  gracile,  and  their  epithelium  is  somewhat  flattened 
and  degenerated.  But  few  pseudo-glands  are  present.  On  macroscopic  examination  a  little  pus  could  be  seen 
in  tlie  tube.     The  abdominal  ostium  was  open,  although  somewhat  contracted  (X  16). 


PATHOLOGIC    CHANGES    PRODUCED    BY   THE    GONOCOCCUS  109 

occurring  chiefly  within  the  uterine  musculature,  these  abscesses 
should  by  no  means  be  classed  as  intramural  uterine  abscesses.  They 
are  strictly  tubal  in  origin. 

Pyosalpinx. — This  is  the  usual  termination  of  a  salpingitis,  but 
may  occasionally  result  from  a  secondary  infection  of  a  hydrosalpinx. 
The  actual  method  of  closure  of  the  external  abdominal  ostium  is  still 
somewhat  in  doubt.  Doran,^  Kleinhaus,-  Opitz,^  Ries,^  and  Young^ 
have  devoted  papers  to  a  description  of  the  manner  of  closure  of  these 
tubes.  The  last-named  observer  summarizes  the  various  theories  as 
follows,  dividing  them  into  two  classes:  Class  1  includes  those  theories 
that  explain  the  process  as  being  due  to  an  increase  in  the  total 
length  of  the  tube-wall,  which,  by  expanding  in  an  outward  direction, 
becomes  projected  beyond  the  tubal  fimbrise.  According  to  the  theory 
of  Doran,''  and  Kleinhaus,^  the  increase  in  length  is  dependent  on 
swelling  and  increase  in  the  substance  of  the  tube-wall,  associated  with 
salpingitis,  etc.  According  to  Ries,**  the  gliding  outward  of  the  "peri- 
toneal ring'"  over  the  fimbriae  is  rendered  possible  by  the  fact  that  the 
walls  become  loose  and  redundant  subsequent  to  the  collapse  of  a  dis- 
tended tube.  In  Class  2  are  included  the  theories  of  Opitz^  and  Young; 
the  first  explains  the  process  as  due  to  a  retraction  of  the  muscularis 
and  mucosa  of  the  tube  within  the  serous  coat,  and  the  latter^"  claims 
that  the  gliding  process  involves  only  the  mucosa  and  inner  coat  of 
the  muscularis.  The  so-called  perimetritic  closure  of  Doran"  is  ex- 
plained by  the  matting  together  of  the  fimbriae  by  inflanunatory  ad- 
hesions without  preliminary  recession.  The  latter  obviously  rarely 
occurs  in  gonorrhea.  In  many  instances  the  intramural  portion  of 
the  tube  i)rol)al)ly  becomes  occluded  somewhat  earher  than  does  the 
external  abdominal  ostium.  This  occlusion  is  the  result  of  agglutina- 
tion of  the  mucosa.  In  some  cases  this  becomes  permanent,  whereas 
in  others  leakage  occurs  at  irregular  intervals.  In  some  specimens  the 
occlusion  is  largely  induced  mechanically,  as  the  result  of  a  kink  or 
bond. 

Pyosalpinges  vary  markcdl}-  in  size.     Enormous  tul)al  abscesses 

'  Doran,  A.:  Trans.  London  01).st.  Soc,  December  4,  1889. 

'  Kleinhaus:   Veit's  Handbuch,  first  edition,  vol.  iii,  \o.  22,  p.  690. 

'Opitz:  Zeit.  f.  Geb.  u.  Gyn.,  1904,  vol.  Iii,  p.  48.'). 

*  Hies,  E.:  Amer.  Jour.  Obst.,  August,  1909. 

'  Young,  .J.:  Jour.  Obst.  and  (lyn.,  Hrilish  Knipire,  1910,  vol.  xvi,  p.  307. 

'  Ooran,  A.:  Trans.  London  Obst.  ,Soc.,  D.'eciiibiT  4,  1889. 

'  Kleinhaus:  Veit's  Hamlburh,  first  edition,  vol.  iii,  \o.  22.  p.  (V.X). 

•  Rica,  E.:  Amor.  Jour.  Obst.,  .Vugust,  1909. 
"Opitz:  Zeit.  f.  Geb.  u.  Gyn.,  1904,  vol.  Iii,  p.  IS."). 

'"Young,  J.:  Jour.  Obst.  and  Gyn.,  British  Empire,  1910,  vol.  xvi,  p.  .{07. 
"  Doran,  A.:   Trans.  London  Obst.  ,S,,c.,  Diveniber  4,  1889. 


no  GONORRHEA    IN    WOMEN 

have  been  described  by  Richardson/  Genter,^  and  others.     In  Richard- 
son's case  the  pyosalpinx  was  at  first  mistaken  for  a  large  myoma  of 
the  uterus.     The  distended  tube  extended  upward  to  the  umbiUcus. 
The  author  has  operated  in  the  Philadelphia  Hospital  upon  a  case  of 
pelvic  inflammatory  disease  in  which  one  pyosalpinx  measured  14.75 
cm.  in  length  and  had  a  diameter  of  5.5  cm.,  while  the  tubal  abscess 
on  the  opposite  side  measured  13  cm.  by  7.5  cm.  in  diameter.     Such 
huge  dimensions,  however,  are  extremely  unusual.     The  surface  of  the 
tube  is  .covered  with  dense  adhesions,  and  is  sometimes  greatly  con- 
gested, producing  a  dark-red  color,  while  in  other  specimens  the  tube 
has  a  yellowish  tint.     A  pyosalpinx  is  usually  of  a  sausage  shape, 
the  enlargement  being  confined  chiefly  to  the  distal  two-thirds  of  the 
tube.     The  tubes  may,  however,  be  cylindric  or  even  pear  shaped. 
The  uterine  extremity  of  the  tube  may  be  but  little  enlarged.     Only 
rarely  are  fimbria;  visible.     The  tubes  are  frequently  bent  upon  them- 
selves, and  more  or  less  thickening  and  induration  are  always  present 
in  the  mesosalpinx.     The  walls  of  the  tube  vary  widely  in  different 
cases,  the  thickness  bearing  no  relation  to  the  diameter  of  the  tube  or 
of  the  lumen.     In  some  small  pyosalpinges  the  walls  are  thick,  whereas 
in  those  of  large  size  they  may  be  thin,  or  the  reverse  may  be  observed. 
As  a  rule,  the  walls  are  moderately  thick— much  thicker  than  when  the 
contents  are  serous.     The  walls  are  often  friable  and  edematous. 
The  lumina  vary  in  size,  the  greatest  amount  of  dilatation  nearly 
always  being  found  in  the  ampulla.     In  recent  cases  the  mucosa  is  in- 
tact, but  in  old  chronic  specimens  it  may  be  entirely  disintegrated  and 
replaced  by  a  pyogenic  membrane  or  by  granulation  tissue.     The  con- 
tents of  the  lumen  are,  as  a  rule,  moderately  thick,  and  consist  of 
yellowish,  greenish,  or  brownish  pus.     In  acute  cases  gonococci  can 
almost  invariably  be  recovered  from  the  pus,  either  by  culture  or  smear. 
Gurd'  beheves  that  the  reason  cultures  frequently  prove  negative  is 
that  the  material  is  generally  taken  from  the  free  pus,  in  which  locality 
the  organisms  are  often  dead,  disintegrated,  or  at  least  attenuated. 
If  the  cultures  are  made  from  portions  of  curetings  scraped  from  the 
tubal  mucosa  and  underlying  tissue,  gonococci  can  more  often  be 
demonstrated.     As  has  been  stated  by  Wolff,^  the  cytologic  examina-, 
tion  of  the  tubal  contents  is  at  best  unreliable  for  the  diagnosis  ofj 
gonorrhea.  | 

Histology. — The   microscopic    picture    varies   widely   in    different j 

'  Richardson:   Johns  Hopkins  Hosp.  Bull.,  January,  1909,  p.  21. 

2  Center,  G.:  Vrach.  Gaz.,  St.  Petersburg,  1911,  vol.  xviii,  p.  829. 

=  Gurd,  F.  B.:  Jour.  Med.  Research,  1910,  vol.  xxiii;  new  series,  vol.  xviii,  pp.  151-184. 

*  Wolff,  A.:  Zent.  f.  Gyn.,  Leipzig,  1912,  vol.  xxxvi,  No.  49. 


Till 


spec- 1 


I'll  hi 


into  jm  ab.sceH»  cavity. 
IcinkL-il  upon  itself.  On 
rcplar'c(i  by  a  pyoKCnic 
the  sfiit  of  a  mtnihir  It^si 


I'IG.    18, —  INITSUALLY     LaHGK    PyOHAI.IMN  X. 

iriirikcn  to  two-thirds  its  original  si»o.  Practirnlly  the  <.'iiti 
Tho  surface  presents  a  number  of  dense,  fan-like  adhcsi 
lection,  the  walls  are  found  to  be  thickened  and  cdoniatoiis 
iienibrane.     The  lumen  contains  thick,  Kroenish-yellow  pu 


V  tulK-hiisbeenc.iiverted 
jns.  The  tube  is  sharply 
anfl  the  nnicoHti  is  lar^Eely 
i.     The  opposite  tube  was 


L.-Vf'* 


I 


Fig.  19. — Section  Through  an  Advanced  Chronic  Pvosalpin.x. 
The  peritoneal  coat  shows  a  few  adhesions.     The  muscularis  is  thioliened,  infiltrated  i 
products,  and  contains  an  excess  of  fibrous  tissue.     The  blood-vessels  e 
the  surface  epithelium  is  either  desquamated  or  greatly  degenerated. 
have  become  agglutinated,  and  the  development  of  small  pseudo-glands  has  resulted.     The  stroma  of  the  mucos* 
is  infiltrated.     The  most  marked  pathologic  changes  are  observed  near  the  surface  (  X  12). 


iimatory 

ngorged,  the  mucosa  is  thickened,  and 
In  many  cases  the  swollen  mucous  folds 


PATHOLOGIC    CHANGES    PRODUCED    BY   THE    GONOCOCCUS  111 

specimens.  All  the  coats  of  the  tube  are,  however,  more  or  less  in- 
filtrated with  inflammatory  products.  The  mucosa  is,  as  a  rule,  most 
severely  involved.  The  infiltration  is  especially  profuse  about  the 
blood-  or  lymph-vessels.  This  is  particularly  noticeable  in  the  mus- 
cularis.  As  has  been  stated,  the  mucosa  may  be  entirely  absent; 
more  often,  however,  the  phcje  are  swollen,  and  the  investing  epithe- 
lium is  more  or  less  degenerated,  and  frecjuently  irregular  in  size,  shape, 
and  staining  properties.  In  some  specimens  the  epithelium  is  intact, 
whereas  in  others  extensive  areas  of  desquamation  can  be  observed. 
It  is  probable  that,  under  favorable  circumstances,  areas  of  desquamated 
epithelium  are  sometimes  replaced  by  new  cylindric  cells — the  so- 
called  plastic  epithelium  of  Menge.^  In  many  instances,  as  a  result 
of  gonorrhea,  the  tubal  epithelium  loses  its  cilia.  This  is  said  by  many 
authors  to  be  one  of  the  etiologic  factors  in  the  production  of  extra- 
uterine pregnancy.  Occasionally  metaplasia  of  the  tubal  epitheUum 
to  cells  resembling  the  squamous  type  is  observed. 

Pseudo-glands,  formed  by  the  agglutination  of  the  tips  of  the  mu- 
cous folds,  are  frequently  present.  These  vary  much  in  size  and  in  dif- 
ferent specimens.  In  chronic  cases  the  muscularis  contains  an  ex- 
cess of  fibrous  tissue  and  is  more  .or  less  densely  infiltrated  with  in- 
flammatory products.  Large  numbers  of  plasma  cells  are  usually 
observed.  These  are  found  not  only  in  the  muscularis,  but  also  in 
the  mucosa  and  in  the  lumen.  They  are  usually  arranged  in  clusters. 
Leukocytes,  except  in  acute  cases,  are  seldom  present.  Lymphocytes, 
the  lymphoblasts  of  Schridde,^  or  large  lymphocytes,  and  also  Krom- 
pecher's'  mast  cells,  are  often  seen.  The  last-named  are  moderately 
large  cells,  which  contain  coarse,  deeply  staining  basophilic  granules, 
and  possess  a  nucleus  similar  in  shape  and  staining  properties  to  that 
of  the  plasma  cell.  Occasionally  a  few  hyaline-hke,  homogeneous, 
pink-staining  bodies,  six  or  seven  times  the  size  of  a  plasma  cell,  may 
be  observed.  These  are  known  as  Russel's  bodies.  Mitosis  is  fre- 
quent. The  serosa  is  thickened,  and  a  well-developed  inflammatory 
membrane  of  exudate,  consisting  of  a  fine  fibrous  meshwork,  in  which 
numerous  small  round-cells,  polymorphonuclear  leukocytes,  or  free 
blood  may  be  present,  according  to  the  stage  of  the  disease. 

Hydrosalpinx. — This  condition,  as  its  name  indicates,  is  a  dis- 
tention of  the  tube  with  serous  or  watery  fluid.  These  tubal  enlarge- 
ments may  lie  produced  in  three  ways:    (1)  By  an  inflanunation  from 

'  MniKP,  K.:   Hand.  d.  GeschU'chtskrankhciten,  Vienna,  1910. 

'Schriddo:  Munch,  mcd.  Woch.,  1908,  No.  20;  also  Dcutsch.  mod.  Woch.,  190S,  vol. 
xxviii,  p.  r_'.")l. 

'  Kroinpcchcr:   Zioglcr's  Bcitrage  f.  all.  Path.,  1898,  vol.  xxiv,  p.  1().'5. 


112  GONORRHEA    IN    WOMEN 

within  which  seals  both  ends  of  the  tube  and  allows  fluid  to  accumulate 
within  the  lumen.  The  mechanism  under  these  circumstances  is  very- 
similar  to  that  which  produces  a  pyosalpinx,  differing  only  in  the  fact 
that  the  inflammation  does  not  progress  to  the  stage  of  pus-formation. 
These  specimens  are  known  as  pseudofollicular  hydrosalpinges  and 
are  the  most  frequent  variety  of  a  gonorrheal  hydrosalpinx.  As  in  the 
production  of  a  pyosalpinx,  the  closure  may  be  largely  the  result  of 
inflammatory  stimuli  from  without  the  tube — the  perimetritic  closure 
of  Doran.i  In  this  type  the  chief  inflammatory  changes  are  found  in 
the  outer  layers  of  the  tube,  and,  as  a  result,  the  plica  are  not  exten- 
sively involved,  except  by  the  changes  resulting  from  intratubal  pres- 
sure. These  are  the  specimens  which  are  described  in  the  literature 
as  sactosalpinges  simplex,  and  are  rarely  of  gonorrheal  origin.  They 
often  assume  a  large  size.  They  are  generally  of  puerperal  origin,  and 
may  be  due  to  an  infection  occurring  through  the  lymph-channels  in 
the  broad  Ugament.  Kleinhaus,-  in  a  series  of  15  such  tubal  lesions, 
found  that  11  were  of  puerperal  origin.  The  third  method  of  produc- 
tion of  a  hydrosalpinx  is  by  the  conversion  of  the  pus  in  a  pyosalpinx 
into  serous  fluid.  The  transformation  of  a  pyosalpinx  into  a  hydro- 
salpinx is  probably  of  rare  occurrence.  Menge,'  basing  his  opinion 
on  histologic  grounds,  questions  if  it  ever  occurs.  Bland-Sutton"*  is 
is  of  the  opinion  that  it  occasionally  happens. 

A  hydrosalpinx  may  be  viewed  as  a  form  of  tubal  retention  cyst. 
The  affected  tubes  vary  markedly  in  size,  but  as  a  rule  they  are  con- 
siderably larger  than  are  purulent  collections.  The  author  saw  an 
unusual  case  in  which  two  tumors,  each  the  size  of  a  fetal  head,  were 
present.  On  examination,  one  of  these  proved  to  be  an  enormous 
hydrosalpinx  and  the  other  a  tubo-ovarian  cyst.  Godart^  has  recently 
reported  an  enormous  hydrosalpinx  which,  at  first  sight,  might  easily 
have  been  mistaken  for  an  ovarian  cyst.  The  tumors  are  generally 
retort-shaped,  the  swelling  starting  at  the  inner  portion  of  the  isthmus, 
and  rapidly  widening  out  until  the  outer  portion  of  the  ampulla  is 
reached.  Occasionally  the  enlargement  is  spheric.  In  some  instances 
the  enlargement  occupies  the  entire  extramural  portion  of  the  tube, 
whereas  in  others  only  the  ampulla  is  increased  in  diameter.  The 
external  abdominal  ostium  may  be  totally  obliterated,  or  a  dimple 
may  exist  at  the  site  of  the  tubal  closure.     The  mesosalpinx  does  not 

'  Doran,  A.:  Trans.  London  Obst.  Soc,  December  4,  1889. 
'  Kleinhaus:  Veit's  Handbuch,  vol.  iii. 
'  Menge:  Cent.  f.  Gyn.,  1895,  vol.  xix,  p.  799. 
■•  Bland-Sutton:   Diseases  of  the  Ovaries  and  Fallopian  Tubes,  second  edition,  1896,  pp. 
216-220. 

'  Godart,  J.:   Policlin,  Brux.,  1912,  vol.  xxi,  p.  88. 


1 


■*'*'',r<  -*• 


^^/.>;.,B 


Fl«.    20. btCTIO.N    Tuituuuu    a    rVUHALI'iXX. 

The  surface  preHents  a  few  ndheaions.  The  muaculoris  ia  thickened,  fibrous,  and  infiltrated  with  inflam- 
matory products.  The  niucosn  is  much  thickened.  Large  numbers  of  pseudo-absroHsert  which  vary  consider- 
ably in  size  are  seen.  The  epithelium  is  generally  present,  but  is  markedly  flattened  and  degenerated.  The 
Stroma  is  densely  infiltrated  with  inflammatory  products.     Considerable  pus  is  present  in  the  lumen  (  X  l."»). 


Fig.  21.— HvnKMSALi-iNX. 
The  tub.  ha.  been  converted  into  a  retort-shaped,  thin-walled  eystie  tumor.     The  inner  third  of  the  tube  is 
about  normal  in  dia.uoter.     From  this  point  it  rapidly  widens  out  and  the  walls  become  thin      The  abdommjj 
ostium  is  completely  closed,  and  its  original  location  is  marked  by  a  small  dimple      Un  section,  tnc  w. 
found  to  be  thin,  the  mucosa  is  smooth,  and  the  lumen  contains  clear,  straw-colored  fluid. 


f 


PATHOLOGIC    CHANGES    PRODUCED    BY    THE    GONOCOCCUS  113 

lengthen  out  proportionately  to  the  increasing  size  of  the  tube,  and, 
as  a  consequence,  the  hydrosalpinx  is  generally  considerably  bent  or 
even  kinked  upon  itself.  The  ovary  often  lies  in  the  concavity  of  the 
tube.  Adhesions  are,  as  a  rule,  less  dense  and  numerous  than  when 
the  tube  contains  pus.  Sometimes  the  inner  half  of  the  tube  is  but 
little  enlarged,  and  forms  a  pedicle  for  the  retention  cyst,  which  may  be 
comparatively  free  from  adhesions.  These  are  the  types  of  specimens 
in  which  torsion  is  likely  to  occur.  The  walls  of  a  hydrosalpinx  are 
usually  thin,  and  the  lumen  is  correspondingly  dilated.  In  some  speci- 
mens, when  the  lumen  is  incised,  the  remains  of  the  plkse  can  be  dis- 
tinguished macroscopically,  whereas  in  others  the  lining  of  the  tube 
appeai-s  to  be  smooth.  In  some  instances,  owing  to  the  formation  of 
pseudo-glands,  practically  the  entire  lumen  is  occupied  by  what  ap- 
pears to  be  serous  cysts,  which  vary  widely  in  size,  and  are  generally 
more  or  less  concentrically  arranged  about  a  minute  central  cavity— 
the  true  lumen.  The  contents  of  the  lumen  are  made  up  of  thin, 
yellowish  or  colorless  fluid,  in  which  gonococci  can  rarely  be  demon- 
strated. Occasionally  the  fluid  is  turbid,  or  may  be  dark  from  the 
admixture  of  blood.  In  cases  of  tubal  pregnancy  hydrohematosal- 
pinges  are  frequently  present  in  the  opposite  side,  and  under  such  cir- 
cumstances are  probably  often  due  to  the  admixture  of  blood  incident 
to  the  pregnancy,  to  a  preexisting  hydrosalpinx.  Hydrohematosal- 
pinges  may  also  result  fi'om  tubal  neoplasm,  such  as  i)apill()nui  or 
carcinoma. 

Hydrops  tubae  profluens,  or  intermittent  hydrosalpinx,  is  a  condi- 
tion in  which  the  proximal  end  of  the  tube  is  not  permanently  oc- 
cluded, but  when  the  intratubal  pressure  reaches  a  certain  point,  opens 
out,  allowing  the  tubal  contents  to  escape  through  the  uterus.  In 
these  cases  the  stenosis  at  the  uterine  end  of  the  tube  may  be  inflam- 
matory or  purely  mechanical  in  natiu-c,  resulting  from  a  kink  or  bend 
in  the  tube. 

Histology. — Micros(!opic  examination  can,  as  a  rule,  determine  the 
method  of  formation  of  the  hydrosalpinx.  In  the  case  of  hydrosali)inx 
snnplex,  the  plicsae  are  free,  although  they  are  more  or  less  stunted  and 
then-  epithelium  is  free  from  inflammatory  change.  The  chief  in- 
flammatory lesion  is  situated  in  the  external  layers  of  the  tube.  In 
a  hydrosalpinx  that  was  formerly  a  pyosalpinx  the  muscularis 
contains  a  well-marked  excess  of  fibrous  tissue;  it  is  generally 
more  or  less  infiltrated  with  inflammatory  products,  while  the  epi- 
tliehum  of  the  mucosa,  and  even  the  stroma,  usually  presents  well- 
defined  evidences  of  a  preexisting  destructive  inflanmiation.  In  the 
ordmary  follicular  hydrosalpinx  the  inllanmiatory  reaction  is  confined 


114  GONORRHEA    IN    WOMEN 

chiefly  to  the  mucosa,  and  numerous  pseudo-glands,  formed  by  an 
agglutination  of  the  tips  of  the  mucous  folds,  are  present.  The  epi- 
thelium is  comparatively  normal,  and  does  not  exhibit  the  marked 
inflammatory  changes  seen  in  a  case  of  a  converted  pyosalpinx.  The 
peritoneal  surface  of  a  hydrosalpinx  usually  presents  adhesions;  the 
muscularis  is  thin  and  stretched,  due  to  the  intratubal  pressure,  and 
may  be  more  or  less  infiltrated  with  small  round-cells,  plasma  cells, 
lymphocytes,  polymorphonuclear  leukocytes,  and  serum.  As  a  rule, 
comparatively  few  active  inflammatory  products  are  present.  This, 
however,  depends  largely  upon  the  form  of  the  hydrosalpinx  and  the 
stage  of  the  infection. 

GONORRHEA  OF  THE  OVARIES 
Peri-oophoritis. — As  a  result  of  gonorrheal  tubal  lesions,  more  or 
less  infected  material  escapes  into  the  pelvis  and  over  the  ovaries,  which, 
from  their  situation,  are  particularly  prone  to  be  thus  contaminated. 
As  a  result,  a  peri-oophoritis  develops,  and  the  ovary  may  become 
adherent  to  the  tube,  the  posterior  surface  of  the  broad  ligament,  the 
omentum,  the  bowel,  chiefly  the  rectum  or  sigmoid  flexure,  or  the 
pelvic  peritoneum.  The  changes  taking  place  on  the  surface  of  the 
ovary  and  in  the  pelvic  peritoneum  seem  at  first  to  consist  of  the  forma- 
tion of  a  fine  plastic  membrane  from  which  adhesions  subsequently 
develop.  As  the  result  of  adhesions  and  a  thickening  of  the  capsule 
of  the  ovary,'  retention  cysts,  usually  folUcular  in  nature,  although 
sometimes  of  lutein  origin,  ensue.  Not  infrequently  the  ovary  is 
found  to  be  embedded  in  a  mass  of  adhesions,  but  is  not  otherwise 
involved.  The  method  of  ovarian  infection  and  its  character  in  cases 
of  gonorrhea  are  of  the  utmost  importance,  because  of  their  bearing  on 
conservation  of  the  ovary  when  operating  upon  cases  of  pelvic  inflam- 
matory disease.  The  recognition  of  the  fact  that  in  the  vast  majority 
of  cases  the  infection  is  due  to  surface  contamination,  and  is  not  the 
result  of  gonococci  within  the  ovary,  is  of  the  utmost  importance. 
The  prognosis  in  cases  of  conservation  would  naturally  be  much  less 
favorable  if  the  latter  were  the  case.  In  some  cases  the  disease  may 
subside  without  further  involvement.  In  pelvic  inflanmiatory  disease 
peri-oophoritis  is  the  most  frequent  pathologic  condition  encountered. 
Among  490  ovaries  removed  for  pelvic  inflammatory  disease  in  the 
Gynecologic  Department  of  the  University  of  Pennsylvania,  266  were 
the  seat  of  a  peri-oophoritis,  122  of  an  oophoritis,  in  44  abscesses  were 
present,  17  were  cases  of  tubo-ovarian  cysts,  and  41  were  tubo-ovarian  j 
abscesses,  showing  that  peri-oophoritis  is  more  than  twice  as  frequent  ^ 
as  any  other  inflammatory  lesion.     In  considering  the  frequency  from 


i 


^^^•^^' 


A,^ 


,0"?^ 


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'=^^- 


>-o5  4:=?^-  -^"^5^  "© 


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Flo.  22. — Cross-section  Thhoihh  ax  Ovaiiian  Ausrcss  of  Lutein  Oukiin. 
Thr  prcHfnoc  of  acute  oophorilia  ia  apparnnt.  nml  in  charactprizcd  by  infiltration  of  polymorphonuclrnr 
koryiM.  wrntii.  fni-  blood,  and  a  few  plasma  ccIIb.     The  lutoin  lining  of  tlu>  abiiccsii  can  still  be  (lislinniiishcd. 
1  in  thi'  l.iltiT  l.iiiitifin  that  the  inflammatory  reaction  is  most  intense  ( X  l.i). 


Fig.  23. — Pyosalpinx  and  Ovarian  Ab 
The  tube  has  been  coiiverted  into  a  club-shaped  pyosalpinx.     On  section,  the  walls  were  found  to  be  thick- 
ened and  edematous.     The  ovary  was  enlarged,  covered  with  adhesions,  and  was  found  to  be  the  seat  of  an 
abscess,  evidently  the  result  of  an  infection  of  a  corpus  luteum.     No  communication  existed  between  the  ab- 
scess ca\'ities  of  the  tube  and  ovary. 


Fig.  24.— Tubo-ovarian  Cyst. 

Tb«  tube  has  been  converted  into  a  retort-shaped,  thin-walled  cyst,  the 

large  serous  accumulation  of  the  ova 


I  of  which  communicates  with  a 


PATHOLOGIC    CHANGES    PRODUCED    BY   THE    GONOCOCCUS  115 

a  study  of  the  statistics  just  cited,  it  should  be  taken  into  consideration 
that  this  is  a  conservative  clinic,  and  that  many  ovaries  the  seat  of  a 
peri-oophoritis  have  not  been  removed,  whereas  those  organs  the  seat 
of  a  more  severe  lesion,  such  as  advanced  oophoritis  or  an  abscess, 
have  been  excised  almost  routinely. 

Oophoritis. — In  many  instances  a  peri-oophoritis  may  extend  to  the 
substance  of  the  ovary.  It  has  been  suggested  by  some  authors  that 
in  rare  cases  the  gonococcus  may  reach  the  ovary  by  way  of  the  blood- 
or  lymph-channels  from  either  an  infected  uterus  or  a  diseased  tube. 
Theoretically  this  is,  of  course,  possible,  but  its  occurrence  has,  how- 
ever, never  been  proved  and  is  open  to  grave  doubt.  The  author  has 
never  seen  a  case  of  gonorrheal  peri-oophoritis  or  oophoritis  without  an 
accompanying  endosalpingitis.  The  most  frequent  route  of  infection 
is  through  a  recently  ruptured  folhcle.  As  a  result  of  infection  the 
ovary  becomes  enlarged  and  edematous,  and  the  tendency  for  the 
formation  of  retention  cysts  becomes  increased.  Such  ovaries  are 
rarely  larger  than  a  hen's  egg,  and  are  often  but  Uttle  increased  in  size. 
During  the  chronic  stage  sclerotic  changes  are  common,  and  the  ovary 
may  even  be  smaller  than  normal.  As  a  rule,  multiple  retention  cysts 
are  present.  Occasionally  one  or  two  of  these  show  a  tendency  to 
become  pedunculated,  or  the  cysts  may  be  deep  in  the  ovarian  stroma. 
The  periphery  of  the  organ  is  chiefly  involved,  and  presents  a  more  or 
less  well-marked  inflammatory  reaction  of  either  an  acute  or  a  chronic 
character.  Some  specimens  may  show  a  marked  excess  of  fibrous 
tissue,  whereas  in  others  the  tendency  toward  fibrocystic  degeneration 
may  be  observed.  Very  often  the  number  of  normally  developed 
follicles  is  much  reduced. 

Abscess  of  the  Ovary. — This  usually  results  from  infection  of  a 
follicle  or  a  corpus  lutoum.  The  follicle  ruptures  in  an  ovary  per- 
haps previously  the  seat  of  a  peri-oophoritis,  and  in  this  way  gono- 
cocci  gain  access  to  the  substance  of  the  organ.  As  has  been 
previously  stated,  this  may  result  in  a  simple  oophoritis  or  an  abscess 
may  occur.  I-]ither  a  Graafian  follicle  or  a  corpus  luteum  may,  there- 
fore, become  the  seat  of  suppuration.  Mixed  infections  are  not  in- 
frequent. Jadassohn'  believes  that  these  lesions  are  pseudo-abscesses. 
Sometimes  the  tissue  surrounding  a  Graafian  follicle  or  a  corpus  luteum 
becomes  involved,  and  a  true  interstitial  abscess  results.  A  general 
oophoritis  accompanies  all  ovarian  abscesses.  Interstitial  abscesses 
may,  perhaps,  occasionally  occur  independently  of  the  rupture  of  a 
follicle.  Ovarian  abscesses  vary  from  those  of  microscopic  dimen- 
sions to  those  the  size  of  the  fetal  head  or  even  larger.     The  ovary  can 

'  Jiulassohn;   Verhandl.  dea  IV.  Dculsclicn  Dcrinat.  Kong.,  Vienna. 


116  GONORRHEA    IN    WOMEN 

accommodate  itself  more  readily  to  enlargement  than  can  the 
tube. 

Tubo-ovarian  Cyst. — This  is  a  combination  of  a  hydrosalpinx  and 
a  retention  cyst  of  the  ovary,  the  lumen  of  the  one  communicating 
with  the  cystic  cavity  of  the  other.  This  lesion  is  produced  by  the 
fimbriae  becoming  adherent  to  the  surface  of  the  ovary,  and  the  subse- 
quent rupture  of  a  follicle  at  the  point  of  adhesion.  The  tube  usually 
resembles  an  ordinary  hydrosalpinx,  except  that  the  distal  extremity  is 
adherent  to  or  buried  in  the  ovary.  The  ovarian  portion  of  the  cyst 
is  generally  about  the  size  of  a  lemon,  but  it  may  be  much  larger. 
The  cysts  occasionally  show  a  tendency  to  become  pedunculated,  and 
are  generally  moderately  thin  walled.  The  inner  surface  is  smooth, 
and  the  contents  are  similar  to  those  of  a  hydrosalpinx.  The  com- 
munication between  the  tube  and  ovary  is  usually  a  free  one. 

Tubo-ovarian  Abscess. — The  etiology  of  a  tubo-ovarian  abscess  is 
similar  to  that  of  a  tubo-ovarian  cyst.  Less  frequently  an  ovarian 
abscess  may  rupture  directly  into  the  body  of  an  adherent  tube,  and 
in  this  way  a  communication  between  the  two  be  established.  Tubo- 
ovarian  abscesses  are  generally  somewhat  smaller  than  tubo-ovarian 
cysts,  and  are  likely  to  be  more  adherent.  Occasionally  an  ovary  the 
seat  of  a  tubo-ovarian  abscess  may  also  contain  other  areas  of  suppura- 
tion, and  retehtion  cysts  are  often  present.  In  shape  and  appearance 
the  tube  resembles  an  ordinary  pyosalpinx.  The  pus  in  these  speci- 
mens is  thick,  creamy,  greenish,  yellowish,  or  blood-streaked,  and  dur- 
ing the  acute  stage  it  contains  numerous  gonococci.  During  the 
chronic  stage  gonococci  are  less  abundant,  and  not  infrequently  they 
are  absent  or  of  attenuated  virulence.  Cultures  or  smear  preparations 
should  be  made  from  cureted  particles  of  the  abscess-wall,  rather  than 
from  the  free  pus,  as  the  former  locaUty  is  more  likely  to  contain  active 
organisms.     The  mesosalpinx  is,  as  a  rule,  much  thickened. 


I 


£  r  ? 


Fig.  20.— Ti'BO-ovARiAN  Abscess. 
The  tube  presents  the  usual  appearance  of  a  pyosalpinx.  except  that  the  distal  extremity  is  buried  in  the 
underlying  ovary  and  the  lumen  of  the  tube  communicates  by  a  wide  opening  with  an  ovarian  abscess  that  con- 
stitutes the  greater  bulk  of  the  latter  organ.     The  contents  of  the  abscess  consist  of  moderately  thin,  purulent 
material. 


CHAPTER  IV 
PATHOGENESIS 

Gonorrhea  in  the  adult  is  usually  contracted  tkrough  sexual  inter- 
course. Although  much  has  been  written  of  other  modes  of  infection, 
the  fact  remains — and  but  few  gynecologists  or  genito-urinary  special- 
ists of  wide  experience  will  refute  the  statement — that  of  every  hundred 
gonorrheics,  ninety-nine  contracted  their  infection  through  coitus. 
It  must  be  remembered,  however,  that  gonorrhea  may  be  contracted 
by  other  means,  and  for  this  reason  patients  should  be  given  the 
benefit  of  the  doubt.  One  reason  why  gonorrhea  is  not  often  con- 
tracted except  through  sexual  congress  is  due,  as  has  previously  been 
pointed  out,  to  the  fact  that  if  exposed  to  room  temperature  or  allowed 
to  dry,  the  gonococcus  loses  its  virulence  or  perishes  in  a  few  hours. 
Were  it  not  for  these  characteristics,  gonorrhea  would  be  much  more 
prevalent,  and  epidemics  would  occur  frequently.  With  few  ex- 
ceptions the  gonococcus  develops  only  on  columnar  epithelium,  and, 
therefore,  in  order  to  transmit  infection,  it  is  necessary  for  the  secretion 
containing  the  gonococci  to  be  introduced  upon  such  soil  in  a  com- 
paratively short  time  after  its  discharge  from  its  original  host.  From 
this  it  will  be  ajjparcnt  that  gonorrhea  may,  in  rare  instances,  be  ac- 
quired without  sexual  intercourse,  and  authentic  cases  are  on  record  in 
which  the  disease  has  been  transmitted  through  the  medium  of  in- 
fected towels,  clothing,  surgical  dressings,  douche-nozles,  wat(>r-clos('ts. 
or  even  the  bath-tub  or  the  swimming-pool.  Although  rare  among 
adults,  hand  infection  has  been  observed.  Men  have  been  infected  as 
the  result  of  using  second-hand  condoms,  which  they  obtained  from 
their  female  partners  or  from  the  keepers  of  houses  of  prostitution, 
these  unfortunates  falling  victims  to  the  very  prophylaxis  they  were 
attempting  to  carry  out.  Instances  are  not  lacking  to  show  that  pa- 
tients have  at  times  been  contaminated  through  dirty  instrumenta- 
tion, or  as  a  result  of  improper  aseptic  technic  during  pelvic  examina- 
tions, local  treatment,  (jr  minor  surgical  operations.  Among  children, 
and  in  organs  other  than  the  genitalia,  gonorrheal  infection  usually 
takes  place  by  different  means  than  those  mentioned.  These  modes  of 
infection  will  l)e  dealt  with  under  their  respective  headings. 

When  infection  takes  ])lace,  the  number  of  grjuococci  that  ol)tain 
access  to  the  urethra  or  other  portions  of  the  genital  tract  is  extremely 

117 


118  GONORRHEA   IN   WOMEN 

small.  Wertheim's'  experiments  tend  to  show  that  the  actual  number 
of  gonococci  introduced  upon  the  mucous  membrane  is  of  comparative 
unimportance.  Abrasion  of  the  surface  upon  which  the  organisms  are 
deposited  is  not  necessary  for  infection.  The  period  during  which  the 
organisms  are  multiplying,  and  before  subjective  symptoms  result,  is 
known  as  the  stage  of  incubation.  Accurate  statistics  relative  to  the 
period  required  for  the  incubation  of  gonorrhea  in  women  are  obtained 
with  difficulty,  as  the  initial  symptoms  of  this  disease  in  the  female  sex 
are  often  so  slight,  and  of  so  insidious  or  transitory  a  character,  that 
the  actual  date  of  onset  is  difficult  to  determine  definitely,  and,  as  a 
further  hindrance,  the  onset  is,  as  a  rule,  so  mild  that  the  physician  is 
rarely  consulted  until  the  disease  has  made  considerable  progress. 
In  fact,  when  the  infection  is  confined  to  areas  below  the  internal  os, 
it  is  not  uncommon  for  the  patients  to  be  in  ignorance  of  the  existence 
of  the  disease.  In  the  male  the  condition  is  different,  and  it  is  com- 
paratively easy  to  obtain  accurate  data  on  this  point.  The  following 
statistics  are  gathered  from  the  report  of  470  cases  by  Eisenmann, 
Hacker,  and  Hoelder: 

Period  of  incubation 1  day 


1  day  in 

11  cases 

2  days  ' 

59 

3  .  "  " 

126 

4  "     " 

62 

5   "  " 

49 

6   "  " 

10 

7   •'  " 

63 

8   "  " 

12 

9   "  " 

12 

10   "  " 

23 

11   "  " 

6 

12   "  " 

8 

13   "  " 

6 

14   "  ' 

19 

19   "  ' 

2 

20   "  ' 

1 

case 

30   "  '• 

1 

" 

470  cases 

The  statistics  by  Lanz-  compiled  from  40  carefully  selected  cases 
are: 

Period  of  incubation 1  day    in     2  cases 

"  3  days   "    15     " 

"     "         "  4-7      "     "    17     " 

;;   ;;     "     8-14   "  "   3  " 

"  20  days  or  more  "      3     " 

40  cases 

Keyes'  records  that  the  average  incubation  in  34  primary  attacks 
of  urethritis  was  six  days,  and  that  among  patients  who  had  previously 

'  Wertheim:  Wien.  klin.  Woch.,  1894,  No.  24. 

•  Lanz,  A.:  Arch.  f.  Dermat.  u.  Syph.,  Vienna  and  Leipzig,  1893. 

'  Keyes,  E.  L.:  Diseases  of  the  Genito-urinary  Organs,  1911,  p.  159. 


PATHOGENESIS  119 

had  gonorrhea,  the  average  duration  among  76  cases  was  4.88  days. 
Of  the  primarj-  attacks,  20  per  cent,  appeared  prior  to  the  fifth  day, 
and  of  the  secondary  attacks,  55  per  cent,  became  inanifest  in  a  like 
period. 

From  these  studies  it  will  be  seen  that  the  greatest  number  of  cases 
develop  on  the  third  day,  and  that  more  than  two-thirds  become  evi- 
dent within  the  first  week.  An  incubation  period  of  more  than  ten 
days  is  extremely  rare,  and  the  more  carefully  these  cases  are  observed, 
the  fewer  will  be  found  to  exceed  this  period.  Although  undoubtedly 
authentic  cases  have  been  reported  in  which  the  disease  became  mani- 
fest more  than  two  weeks  after  infection, — and,  indeed,  Lanz  quotes  one 
case  in  which  the  incubation  period  w^as  seventy  daj-s, — such  reports 
should  be  regarded  with  suspicion,  for  even  if  the  patient's  veracity  is 
beyond  dispute  and  a  previous  infection  can  be  excluded,  the  possi- 
bility of  accidental  inoculation  must  always  be  borne  in  mind.  Ex- 
tremely short  periods  of  incubation,  such  as  twenty-four  hours  or  less, 
are  also  open  to  strong  doubt,  and  are  suggestive  of  a  previous  infection. 
In  these  patients  the  condition  is  "generally  due  to  the  lighting  up  of 
an  old  chronic  condition  that  had  previously  been  overlooked.  The 
period  of  incubation  is  of  importance,  at  least  theoretically,  as  it  draws 
a  sharp  line  of  distinction  between  gonorrhea  and  the  traumatic  or 
chemic  inflammations,  the  reactions  of  which  occur  within  a  few  hours 
after  the  injection  of  the  etiologic  factor.  Experimental  inoculations 
with  pure  cultures  of  gonococci  have  produced  a  urethritis  in  periods 
varying  from  twelve  to  seventy-two  hours.  These  variations  in  time 
are  due  to  a  number  of  factors.  Indubitably  great  differences  exist  in 
the  resistance  power  of  various  individuals  to  infection  bj'  the  gonococ- 
cus.  That  different  strains  of  gonococci  have  varj'ing  degrees  of  viru- 
lence has  also  been  pointed  out  by  many  authorities.  Dandier'  sug- 
gests that  the  microorganisms  present  in  acute  gonorrhea  produce  an 
acute  inflammation,  and  that  the  gonococci  from  a  clironic  case,  when 
infecting  another  individual,  produce  a  chronic  condition.  Doderlein 
makes  a  somewhat  similar  statement.  That  some  gonorrheas  are  sub- 
acute from  the  onset  is  true,  but  ample  proof  can  be  adduced  that 
this  theory  does  not  hold  good  in  all  cases.  As  has  previously 
been  stated,  however,  the  virulence  of  the  gonococcus  is  somewhat 
variable.  That  different  degrees  of  virulence  exist  among  gonococci 
is  indicated  by  the  fact  that  several  individuals  contaminated  at  the 
same  .source  have  all  been  observed  to  develop  metastatic  gonorrhea. 
Ahmann's^   experiment   is   still   more   suggestive.     This   investigator 

'  Handler:  Jour.  Amer.  Med.  Assoc,  February  1,  1908,  p.  .339. 
'  Ahmann:  Arch.  f.  Derniat.  u.  Syph.,  1897,  vol.  xxxix,  p.  323. 


120  GONORRHEA    IN   WOMEN 

inoculated  the  health}^  urethra  of  a  man  with  blood  from  an  individual 
suffering  from  a  gonorrheal  septicemia:  not  only  did  a  urethritis 
result,  but  also  a  general  gonorrheal  infection,  with  localization  in  the 
lung  and  synovial  sheaths.  Trauma  to  the  urethra  is  a  predisposing 
factor  to  gonorrhea.  McDonagh'  states  that  the  shorter  the  period  of 
incubation,  the  more  acute  is  the  case  likely  to  be.  The  same  authority 
believes  that  subsequent  attacks  are  prone  to  be  of  longer  duration, 
and  of  a  more  chronic  character,  than  are  first  infections.  First  at- 
tacks are  usually  more  severe  and  acute,  so  far  as  local  manifestations 
are  concerned.  Subsequent  attacks  are  more  prone  to  be  complicated 
by  arthritis,  endocarditis,  or  other  local  or  general  evidences  of  a 
gonosepticemia.  Morton-  believes  that  gonorrhea  in  tuberculous  or 
debiUtated  patients  is  prone  to  be  subacute  from  the  onset  and  to  run  a 
protracted  course.  The  part  attacked  is  also  a  factor  to  be  taken  into 
consideration  in  studying  the  duration  of  the  period  of  incubation, 
some  locations  causing  symptoms  and  being  more  favorable  for  the 
development  of  the  gonococcus  than  others.  Bunuii  rightly  lays 
particular  stress  upon  this  point. 

The  gonococcus  is,  indeed,  a  pecuhar  organism;  it  is  grown  only 
with  extreme  difficulty  on  artificial  media,  perishing  rapidly  if  not  fre- 
quently transplanted,  and  under  such  conditions  easily  destroyed  by 
extraneous  influences,  such  as  heat,  cold,  or  weak  antiseptic  solutions ;  on 
favorable  soil,  however,  like  the  female  genital  tract,  it  produces  a  dis- 
ease the  chronicity  of  which  is  one  of  its  chief  characteristics.  The 
dictum  of  Noeggerath,  "Once  infected  always  infected,"  is  borne  out  in 
a  large  proportion  of  cases,  and  is  true  of  nearly  all  female  patients  that 
'  are  not  subjected  to  proper  treatment.  Indeed,  the  chronicity  of  the 
disease  has  led  to  the  well-known  aphorism  that  ' '  All  attacks  of  gon- 
orrhea are  curable  except  the  first."  Compared  with  other  pyogenic 
microorganisms  like  the  streptococcus  or  the  staphylococcus,  the  gono- 
coccus possesses  little  or  no  power  of  penetration,  and  although  the 
mucous  membranes  are  not  its  only  habitat,  nevertheless  it  is  on  these 
structures  that  it  usually  develops. 

In  the  genital  tract  of  both  men  and  women,  but  more  especially  in 
the  latter,  the  gonococcus  may  lie  dormant  for  indefinite  periods.  In 
women  the  three  areas  most  frequently  infected  are  the  urethra,  the 
cervix,  and  Bartholin's  glands.  In  a  given  case  the  part  infected  de- 
pends upon  certain  conditions.  Thus  if  the  introitus  is  small  or  the 
male  organ  disproportionately  large,  the  urethra  is  most  likely  to  be 
contaminated,  whereas  if  the  pelvic  floor  is  relaxed  and  the  external 

'  McDonagh,  J.  E.:  The  Practitioner,  1909,  vol.  boodi,  p.  534. 

'  Morton,  H.  N.:  Genito-urinary  Dineases  and  Syphilis,  Philadelphia,  1912,  p.  .39. 


PATHOGENESIS  121 

orifice  gaping,  the  cervix  is  most  frequentlj-  infected.  In  women  or 
young  girls  infected  during  an  incomplete  coitus,  or  as  a  result  of  rape, 
the  urethra  and  external  genitalia  are  naturally  most  exposed  to  con- 
tamination. A  urethritis  may  often  be  warded  off  by  washing  out  the 
urethra  by  urination  immediate^  after  an  impure  coitus,  or  infective 
material  may  be  removed  from  the  cervix  by  a  copious  antiseptic 
douche  taken  immediately  after  a  suspicious  intercourse.  These  fac- 
tors doubtless  play  a  decided  part  in  the  infection  of  one  area  and  the 
escape  of  another.  In  the  urethra,  because  of  the  anatomic  formation 
and  the  short  length  of  the  canal,  the  subjective  symptoms  are  usually 
mild,  consisting  of,  at  most,  a  slight  frequency  of  and  burning  on  mic- 
turition, which  rarelj"  last  more  than  a  few  days.  The  chief  symptom 
of  a  cervicitis  is  an  increase,  usually  not  great,  of  leukorrheal  discharge, 
which  usually  also  changes  somewhat  in  character,  whereas  a  bartho- 
linitis often  results  in  nothing  more  than  a  slight  itching  or  irritation  of 
the  vulva.  Even  with  acute  infection  of  all  these  locations  the  symp- 
toms are  sometimes  so  transient  or  of  so  mild  a  character  that  the 
patients,  unless  on  the  lookout  for'infection,  pay  no  heed  to  their  con- 
dition, and  when  the  disease  becomes  chronic,  they  are,  of  course, 
ignorant  of  its  existence.  This  is  especially  likely  to  be  true  if  the 
patient  is  a  woman  of  unclean  habits  or  of  sluggish  sensibilities.  Even 
when  actual  sj'mptoms  are  noticed,  a  feeling  of  shame  will  sometimes 
prevent  the  patient  from  consulting  a  physician,  and  as  the  acute  stage 
disappears  quickly,  the  woman  naturally  believes  that  nothing  serious 
has  occurred  and  the  entire  incident  is  often  forgotten.  Menge^  states 
that  the  manner  in  which  the  disease  is  often  spread  is  as  follows:  A 
husband  infected  with  a  chronic  gonorrhea,  out  of  courtesy  to  his  young 
wife,  and  because  he  does  not  wish  to  cause  her  pain,  does  not  rupture 
the  hymen  at  the  first  intercourse;  hence  the  infectious  semen  is  de- 
posited at  the  orifice  of  the  urethra  and  at  the  openings  of  Bartholin's 
glands.  As  a  result,  an  acute  vestibular  gonorrhea,  urethritis,  and 
bartholinitis  occur.  This  condition,  of  course,  causes  considerable 
pain,  and  intercourse  ceases.  If  the  woman  is  seen  in  this  condition  !)>■ 
a  competent  physician,  she  can  easily  be  tieated  and  the  spread  of  the 
disease  prevented;  but  most  of  these  patients,  on  account  of  a  sense 
of  modesty,  do  not  consult  a  physician,  and  attribute  these  symp- 
toms to  defloration.  As  a  rule,  they  employ  douches,  and  in  this  way 
carry  the  infected  material  from  the  outside  into  the  vagina,  and  thus 
transfer  the  disease  to  the  cervix.  It  does  not  seen>  to  the  author  that 
this  mode  of  infection  is  a  very  frequent  one.  The  incubation  stage  of 
gonorrhea  lasts  at  least  two  or  three  days,  and  it  does  not  appear  likely 
'  .Mongc,  K.:   Hiiiiflbucli  <1.  GeschlechLskrankhciten,  Vicmiii,  lillO. 


122  GONORRHEA    IN    WOMEN 

that,  on  the  average  honeymoon,  the  hymen  would  remain  unruptured 
for  the  period  required  for  the  development  of  subjective  symptoms. 

The  chronicity  of  gonorrhea  attacking  areas  below  the  internal  os 
accounts  for  many  of  the  peculiarities  of  the  disease,  and,  prior  to  the 
discovery  of  the  gonococcus,  proved  a  stumbling-block  to  the  medical 
man,  causing  the  greatest  confusion  regarding  the  etiology  of  the 
condition.  It  can  be  readily  understood  how  it  is  possible  for  a 
woman  innocently  to  infect  a  man.  This,  however,  does  apply  to  the 
average  prostitute,  who  is  always  on  her  guard  for  symptoms  and  is 
usually  aware  of  her  condition.  It  also  explains  the  frequent  cases 
of  infection  from  api^arently  healthy  individuals.  No  trustworthy 
evidence  has  ever  been  adduced  to  show  that  actual  immunity  to  gon- 
orrhea exists  in  the  human  species.  The  frequent  cases  cited,  in  which 
two  or  more  men  have  had  intercourse  with  an  infected  woman  on  the 
same  night,  and  only  one  or  perhaps  two  have  contracted  gonorrhea, 
must  be  explained  on  other  grounds.  It  is  quite  possible  that  in  some 
of  these  instances  a  douche  following  the  first  intercourse  has  saved  all 
but  the  first  man;  personal  hygiene,  such  as  washing  or  urination 
immediately  following,  may  often  prevent  infection.  It  is  a  well- 
established  fact  that  a  female  gonorrheic  may  transmit  infection  at 
one  time  and  not  at  another.  Doderlein'  states  that  men  in  whom  the 
external  urinary  meatus  is  large  are  more  likely  to  contract  gonorrhea 
than  are  those  possessing  a  small,  contracted  orifice.  The  general 
health  of  the  person  exposed,  together  with  the  individual  suscepti- 
bility of  the  individual,  may  also  play  a  small  part  in  the  question  of 
infection.  Lenehan-  has  reported  a  remarkable  case  in  the  man  in 
whom  a  congenital  double  urethra  was  present.  The  upper  and  smaller 
urethra  was  free  from  infection,  but  in  the  lower  a  well-marked  gon- 
orrheal urethritis  was  observed. 

Coitus  with  an  infected  woman  soon  after  her  menstrual  period  is 
extremely  likely  to  produce  infection,  whereas  the  healthy  woman  is 
herself  especially  inceptive  to  gonorrhea  at  this  time.  Indeed,  the 
infectiousness  of  gonorrhea  at  the  menstrual  period  had  led  to  the  com- 
monly accepted  belief,  among  a  certain  class  of  the  laity,  that  the 
disease  may  be  contracted  from  a  healthy  woman  by  coitus  at  this 
time.  This  peculiarity  of  the  disease  may  be  explained  by  the  con- 
gestion of  the  genital  organs  which  is  always  present  at  menstruation, 
and  which  results  in  the  Uberation,  from  the  tissues,  of  more  abundant 
flora  of  gonococci.  The  diminished  acidity  of  the  vaginal  secretion 
which  follow  the  flow  not  only  favors  the  multiplication  of  gonococci 


'  Doderlein:  Quoted  by  Kustner:  Lehrbuch  der  Gynakologie,  1904,  p.  389. 
2  Lenehan,  W.:  Amer.  Jour.  Urol.,  November,  1912,  p.  59S. 


I 


PATHOGENESIS  123 

which  are  already  present,  but  partially  accounts  for  the  peculiar  in- 
ceptiveness  which  uninfected  women  exhibit  toward  gonorrhea  at  the 
menstrual  period. 

Chronic  or,  as  Luther^  prefers  to  designate  it,  latent  gonorrhea,  is 
most  likely  to  evince  exacerbations  after  excesses  of  anj'^  kind  or 
exhausting  physical  exercise;  as  a  consequence,  during  the  periods 
following  such  indiscretions,  intercourse  with  infected  individuals  is 
peculiarly  hkely  to  be  followed  by  infection.  Latent  gonorrhea  is 
characterized  by  the  fact  that  many  gonococci  are  estabhshed  beneath 
the  surface  of  the  mucosa,  but  are  seldom  observed  on  the  surface  or 
in  the  discharge.  A  woman  with  latent  gonorrhea  may  perhaps  co- 
habit with  a  man  for  long  periods  without  transmitting  the  disease. 
The  fact  must  never  be  lost  sight  of  that  for  infection  to  take  place 
the  gonococcus  must  be  brought  in  contact  with  the  mucous  mem- 
brane, and  that  anything  which  tends  to  lessen  the  likelihood  of  this 
occurrence  decreases  the  probabihty  of  contracting  gonorrhea.  In  the 
so-called  latent  cases  of  gonorrhea  the  gonococcus  appears  at  times 
partially  to  lose  its  virulence,  or  the  hosts  become  slightly  immune  to 
their  own  particular  organism.  This  is  probably  more  apparent  than 
real.  Nevertheless,  such  individuals  may  infect  others,  or,  in  some 
cases,  themselves  cohabit  with  infected  persons  without  developing 
symptoms  of  an  acute  attack.  These  constitute  the  class  of  persons, 
occasionally  met  with,  who  seem  to  be  immune  to  gonorrhea.  In 
chronic  gonorrhea  the  secretions  may  for  a  time  contain  few  or  no 
gonococci.  This  fact  is  amply  borne  out  by  clinical  and  bacteriologic 
evidence.  A  curious  feature  of  gonorrhea  is  shown  by  the  fact  that  a 
husband  may  infect  his  wife,  and  practise  abstinence  during  the  course 
of  the  treatment  of  his  disease  may,  upon  resuming  marital  relations 
be  inoculated  by  her  and  develop  an  attack  pcrhajis  more  severe  than 
his  original  one,  or  husband  and  wife  may  both  suddenly  manifest 
severe  symptoms.  A  lack  of  knowledge  of  this  peculiarity  of  the 
microorganism  has  frequently  led  to  accusations  of  infidelity.  A 
curious  example  of  this  queer  feature  of  the  disease,  and  one  instanc- 
ing the  peculiar  latency  and  chronicity  of  gonorrhea,  came  under  the 
author's  notice  a  few  years  ago:  Six  weeks  after  marriage  the  hus- 
band, who  was  ten  years  older  than  his  wife,  was  forced  to  leave  home 
on  an  extended  trip;  upon  his  return  his  wife  informed  him  (hat  she 
had  developed  a  purulent  leukorrhea  a  few  days  after  his  departure. 
The  family  physician  was  consulted,  and  he  pronouncetl  the  wife's 
condition  to  be  gonorrhea,  the  tyi)ical  organisms  being  found  in  smear 
prejiarations.  On  this  evidence  the  husband  instituted  divorce  pro- 
'  Luther:   Monats.  f.  (_!eb.  u.  Ciyiiiik.,  vol.  xvii,  \o.  I,  p.  71. 


124  GONORRHEA    IN   "WOMEN 

ceedings,  based  on  infidelity.  Fortunately,  at  this  period  the  wife 
visited  a  gynecologist,  who  induced  the  husband  to  stay  the  legal  pro- 
ceedings until  after  he  had  been  examined  by  a  genito-urinarj^  special- 
ist. Up  to  this  time  the  husband  had  denied  infection,  and,  indeed, 
no  subjective  or  objective  symptoms  of  a  chronic  gonorrhea  could  be 
elicited  by  any  of  the  ordinary  means.  Repeated  cultures  and  smears 
from  the  urethra  were  negative,  and  it  was  not  until  deep  massage  of 
the  prostate  had  been  resorted  to  that  gonococci  could  be  demon- 
strated. It  was  only  then,  when  confronted  with  this  incontrovertible 
evidence  of  his  infection,  that  the  husband  could  be  convinced  of  his 
condition.  He  admitted  later  that,  twenty  years  previously,  when 
quite  a  young  man,  he  had  suffered  from  a  slight  urethral  discharge 
that  had  appeared  after  an  illicit  coitus — the  only  time  in  his  life,  so 
he  stated,  that  he  had  had  intercourse  with  a  woman  other  than  his 
wife.  In  this  case  both  husband  and  wife  were  persons  of  a  high  degree 
of  veracity  and  integrity,  and  there  is  every  reason  to  believe  that  their 
statements  were  true. 

Regarding  the  persistence  of  the  gonococcus  in  the  prostate,  opin- 
ions differ.  Cohn,^  Wossidle,-  and  Goldberg'  believe  that  the  organism 
is  rarely  found  in  this  location  after  two  years.  On  the  other  hand, 
Finger,*  Neisser,^  and  Putzler  express  a  contrary  opinion.  Sax^  re- 
ports a  case  in  which  gonococci  persisted  in  the  prostate  for  fourteen 
years.  MacMunn"  relates  a  somewhat  similar  case  in  which  a  man 
infected  his  wife  fifteen  years  after  contracting  gonorrhea;  Valentine* 
reports  a  still  more  remarkable  case,  in  which  a  man  infected  his  wife 
thirty  years  after  his  apparent  cure,  and  after  having  fulfilled  his 
marital  relations  with  her  for  twenty-four  years.  Apetz^  reviews  a 
case  of  gonorrhea  after  six  years  without  fresh  infection,  but  with  a 
concomitant  outbreak  of  polyarthritis  and  metastatic  conjunctivitis 
and  other  eye  complications.  Such  instances  are,  however,  extremely 
unusual.  Gonorrhea  in  the  female  may  persist  indefinitely,  but  in  the 
male  a  course  of  more  than  three  or  four  years  is  extremely  rare  and 
should  be  viewed  with  suspicion;  in  the  majority  of  cases  a  reinfection 
is  more  than  likely  to  have  occurred,  von  Notthaft"*  states  that  it  is 
unusual  for  gonorrhea  to  persist  in  the  genital  tract  in  the  male  for 

'  Cohn:  Cent.  f.  Krankh.  d.  Ham-  u.  Se.-tualorgane,  1898,  p.  229. 

'  Wossidle:  Die  Gonorrhoe  des  Mannes  u.  ihre  Komplikationen,  Berlin,  1903,  p.  206. 

'  Goldberg:   Cent.  f.  Krankh.  d.  Harn-  u.  Sexualorgane,  1906,  vol.  xvii,  No.  5. 

*  Finger:   Die  Blennorrhoe  der  Sexualorgane,  1905. 
'Neisser:  Verhandl.  d.  Deut.  Dermat.  Gesellsch.,  Vienna,  1894. 

*  Sax:  Trans.  Amer.  Urol.  Assoc,  1909,  Brookline,  1910,  vol.  iii. 
'  MacMunn,  J.:  Lancet,  November  24,  1906,  p.  144.5. 

*  Valentine,  F.  C:  Phila.  Med.  Jour.,  July  8,  1899. 
5  Apetz,  W.:  Miinch.  med.  Woch.,  vol.  1,  p.  1340. 

1°  V.  Notthaft:  Arch.  f.  Dermat.  u.  Syph.,  1904,  vol.  Ixx,  p.  277. 


PATHOGENESIS  125 

more  than  three  years,  and  Keyes^  writes  that  he  has  never  known  the 
gonococcus  to  survive  in  a  male  host  for  more  than  a  similar  period, 
and  that  in  at  least  90  per  cent,  of  cases  they  disappear  with  or  with- 
out treatment  within  a  year.  On  the  other  hand.  Pollock  and  Harri- 
son- believe  that  in  a  large  proportion  of  cases  recovery  is  not  complete. 

Husband  and  wife  may  cohabit  regularly  and  may  both  ho  infected, 
and  yet  manifest  no  subjective  symptoms  of  the  disease,  whereas  a  third 
individual  having  intercourse  with  either  one  may  develop  an  acute 
attack,  or  the  gonococci  of  a  married  pair  may  be  transferred  to  a 
third  person,  and  from  them  to  one  of  the  couple,  setting  up  a  severe 
lesion  in  its  original  host.  These  instances  are  sufficient  to  show  that 
gonococci  maj'  remain  latent  for  prolonged  periods,  but  that  when  trans- 
ferred to  another  individual,  are  capable  of  setting  up  severe  inflamma- 
tion, and  may  be  transferred  either  through  the  second  or  by  a  third 
person  to  the  original  host,  and  in  the  latter  produce  an  acute  attack. 

Jadassohn^  has  suggested  that  some  chronic  gonorrheas  may  be 
rendered  acute  by  superinfection  with  their  own  gonococci.  Gono- 
cocci may  lie  dormant  in  the  genital  tract  of  women  for  j^ears,  becom- 
ing active  with  the  advent  of  pregnancy,  miscarriage,  or  abortion, 
and  then  produce  sepsis.  Women  are  usually  infected  by  men  suf- 
fering from  chronic  uretliritis.  An  old  gleety  discharge  ("morning 
drop")  is  one  of  the  most  prolific  causes  of  infection.  Men  so  afflicted 
frequently  consider  themselves  cured,  or  may  actuallj^  be  told  so  by 
some  hard-worked  physician,  who  has  neither  the  time  nor  the  knowl- 
edge and  facilities  required  to  make  a  thorough  examination.  On  the 
other  hand,  a  chronic  urethritis  maybe  present  in  the  man  and  produce 
absolutely  no  symptoms  until  a  slight  excess  of  alcohol  may  give  rise 
to  a  mild  exacerbation,  at  which  time  the  urethral  discharge  may  con- 
tain virulent  gonococci.  The  prevalence  of  gleet  is  well  known,  and 
largely  accounts  for  the  frequency  of  gonorrhea  among  married  women. 

Racial  Susceptibility.— It  is  difficult  to  determine  if  any  racial  sus- 
ceptibility to  gonori'hea  exists.  It  is  connnonly  asserted  that  the 
African  race  is  peculiarly  susceptible  to  gtmorrhea.  It  ap])ears  to  be 
a  fact  that  gonorrhea  is  relatively  more  frequent  among  negroes  than 
among  whites.  What  proportion  of  this  can  be  laid  at  the  door  of 
immorality  and  uncleanliness  is  impossible  accurately  to  estimate, 
but  this  is  probably  the  chief  factor.  Research  has  failed  to  sliow 
that  gonorrhea  is  more  malignant  in  new  peoples  than  in  those  in- 
accustomed  to  the  disease  for  generations,  and  it  seems  likely  tiuit  the 
fection  is  quite  as  severe  at  the  present  date  as  it  was  g(>n(Tations  ago. 

'  Koyes:  Amer.  Jour.  Med.  Sei.,  Jiinuary,  lOl'i. 

'Pollock,  C.  E.,  ami  Harrison,  L.  \V.:  (!onocoeciil  Infi'clion,  I.oimIoii,  HHJ,  p.  HI 

'  Jadas.sohn:   C'lirn'sp.iinlciiz-BI.  f.  .schw.  .Verzli-,  M;iy  1,  lx'."><. 


CHAPTER  V 

SOCIOLOGY 

The  general  and  wide-spread  evil  effects  of  gonorrhea  can  hardly 
be  overestimated.  There  is  probably  no  other  disease  known  to  naedi- 
cal  science  that  has  caused  as  much  suffering  and  sorrow  throughout 
the  civilized  world  as  has  gonorrhea.  Neisser  states  that,  with  the 
exception  of  measles,  gonorrhea  is  the  most  wide-spread  of  all  diseases. 
It  is  the  most  potent  factor  in  the  production  of  involuntary  "race 
suicide,"  and,  by  sterilization  and  abortion,  does  more  to  depopulate 


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Fig.  27. — Age  Distribution  of  Death  from  Venereal  Disease,  Per  Cent.  (Brown,  H.  A.:  New  York 
Med.  Jour.,  June  17,  1911,  p.  1185). 

the  country  than  does  any  other  one  cause.  The  number  of  deaths 
annually  that  can  be  traced  directly  to  this  disease  is  difficult  to  esti- 
mate, but  it  is  undoubtedly  large.  The  majority  of  deaths  due  di- 
rectly to  this  disease  are  usually  tabulated  under  other  headings  in 
mortality  statistics.  An  example  of  this  in  the  recent  Mortality 
Statistics^  issued  from  Washington  in  which,  from  1900  to  1909,  the 
average  death-rate  due  to  gonorrhea  (excluding  stillbirth)  for  both 

'  Mortality  Statistics,  1909,  Department  of  Commerce  and  Labor,  Bureau  of  Census, 
Washington,  1912,  p.  86. 

126 


SOCIOLOGY  127 

infants  and  adults  is  placed  at  31  and  32  per  100,000  respectively. 
These  statistics  are  misleading,  as  they  refer  only  to  the  cause  of  death, 
as  stated  in  the  death  certificate,  and  naturally  do  not  include  the 
vast  number  of  deaths  that  are  directly  due  to  gonorrhea,  and  that 
are  usually  recorded  in  the  death  certificate  as  pelvic  abscess,  peri- 
tonitis, septicemia,  etc. 

Of  the  500,000  prostitutes  who  constitute  a  part  of  the  population 
of  our  great  cities,  it  is  estimated  that  40,000  die  annually.  Of  these 
deaths,  30  per  cent,  are  due  to  gonorrhea.  Among  the  deaths  follow- 
ing abdominal  operations  a  very  definite  percentage  can  be  traced  to 
this  type  of  infection.  Price  asserted  that  90  per  cent,  of  all  pelvic 
infections  are  of  gonorrheal  origin.  Norris,  whose  statistics  were 
compiled  from  dispensary  patients,  places  the  proportion  at  80  per 
cent.;  Pozzi  and  Frederic,  at  75  per  cent.;  Clark,  at  50  per  cent.; 
Daxis  and  Noble,  at  from  5  to  10  per  cent. ;  and  Robb,^  at  25  per  cent. 
Grandin  states  that  60  per  cent,  of  all  gynecologic  operations  are  per- 
formed for  gonorrhea  or  its  results.  Kaan-  states  that  in  Boston  from 
5  per  cent,  to  16  per  cent,  of  all  gynecologic  operations  are  performed 
for  gonorrhea.  This  author  believes  that  many  writers  place  too  much 
stress  upon  the  gonococcus  as  an  etiologic  factor  in  pelvic  inflammatory 
diseases.  Kaan's  report  is,  however,  based  upon  clinical  findings 
only,  no  bacteriologic  studies  having  been  performed  upon  the  cases 
reported  bj'  him.  Morrow  and  Bridgman^  report  th^t  in  the  State 
Training  School  for  Girls  at  Geneva,  Illinois,  approximate!}'  55  per 
cent,  of  the  inmates  have  gonorrhea  at  the  time  of  their  entrance. 
The  average  number  of  commitments  a  year  to  this  school  is  about 
200. 

Statistics  computed  from  the  reports  of  Briise,  Sanger,''  and  Eber- 
hard  show  that  in  a  series  of  1361  gynecologic  patients,  12.77  per  cent, 
were  infected  with  gonorrhea.  From  these  figures,  therefore,  placed 
at  a  conservative  estmatc,  gonorrhea  may  be  said  to  cause  at  least 
50  per  cent,  of  all  pelvic  inflammatory  diseases. 

The  percentage  of  sterility  traceable  to  gonorrhea  is  more  difficult 
to  estimate.  Neisser,  ]5unun,  and  Furl)riiiger  state  that  30  per  cent, 
to  50  per  cent,  of  all  childless  marriages  are  directly  caused  by  gon- 
orrhea. In  France  statistics  have  been  accurately  comi)ilcd,  and  it 
has  been  found  that,  of  about  10,000,000  families,  2,000,000  are  with- 
out issue.     These  results,  according  to  Neisser,  would  tend  to  show 

'  Robb:  Trans.  Amer.  Gyn.  Soc,  1906. 

'  Kaan,  G.  W.:  Boston  Med.  and  Surg.  Jour.,  April  11,  1912,  p.  559. 

•  Morrow,  L.,  and  Bridgnian,  O.:  Jour.  Amor.  Med.  Assoc,  May  25,  1912,  p.  I")!)}. 

*  Sanger,  W.  W. :   History  of  Prostitution,  1906. 


128  GONORRHEA    IN   WOMEN 

that  gonorrhea  is  the  etiologic  factor  in  nearly  1,000,000  sterile  mar- 
riages in  France  alone,  and  this  does  not  include  the  vast  number  of 
"  one-child  sterilities"  due  to  this  condition.  Other  authorities  place  the 
proportion  of  sterility  resulting  from  gonorrhea  at  figures  varying  from 
30  per  cent,  to  50  per  cent.  Funck-Brentano  and  Plauchu,^  in  a  series 
of  134  sterile  women,  found  that  in  37  the  condition  was  due  to  gon- 
orrhea. Lobenstine  and  Harrar-  found  that  the  average  birth-weight 
of  the  infants  of  gonorrheal  mothers  was  lower  than  of  babies  of 
mothers  unaffected  with  this  disease.  Their  conclusions  were  based 
on  the  observation  of  150  babies  of  normal  mothers,  as  compared  with 
50  babies  of  afebrile  gonorrheal  mothers,  and  50  babies  of  gonorrheal 
mothers  with  fever.  The  birth-weight  of  these  infants  was  lower,  the 
initial  loss  of  weight  greater,  and  the  subsequent  gain  slower,  than  in 
babies  of  non-gonorrheal  mothers.  These  authors  consider  that,  in 
the  late  months  of  pregnancy,  gonorrhea  is  a  frequent  cause  of  pre- 
mature births.  Many  authors  claim  that  placenta  prsevia  and  ad- 
herent placenta  are  often  caused  by  a  preexisting  gonorrheal  endome- 
tritis, but  this  has  not  yet  been  definitely  proved.  Placed  at  a  low 
estimate,  gonorrhea  may  be  said  to  cause  20  per  cent,  of  all  the  blind- 
ness in  the  world.  In  the  United  States  census  for  the  blind  and  deaf 
for  1900  it  was  shown  that  ophthalmia  neonatorum  was  the  cause  of 
25.02  per  cent,  of  all  the  blindness.  It  has  been  computed  that,  in 
Prussia,  venereal  diseases  cause  an  annual  loss  to  the  State  of  90,000,- 
000  marks  ($21,600,000).  The  Royal  Commission  on  the  Blind,  the 
Deaf,  and  the  Dumb,  which  reported  in  1889,  estimated  that  7000 
persons  in  the  United  Kingdom  had  lost  their  sight  as  a  result  of 
ophthalmia.  They  state  further  that  the  number  of  people  disabled 
as  a  result  of  this  condition  represents  an  annual  burden  to  the  com- 
monwealth of  £350,000.  There  is  every  reason  to  believe  that  gon- 
orrhea and  other  venereal  diseases  are  quite  as  prevalent  in  this  coun- 
try as  in  Europe. 

Frequency. — On  account  of  the  secret  nature  of  the  malady,  the 
frequency  of  gonorrhea  in  civil  life  is  difficult  to  estimate  accurately, 
and  more  especially  is  this  the  case  with  gonorrhea  in  the  female. 
In  1901  the  Committee  of  Seven^  on  Prophylaxis  of  Venereal  Diseases 
in  New  York  sent  out  a  circular  letter  to  4750  physicians  in  New  York 
City  asking  for  data  regarding  venereal  disease.  A  large  number  of 
the  hospital  and  dispensary  reports  from  the  same  city  were  also 
examined.     It  was  estimated  by  this  Committee  that  at  that  time 

'  Funck-Brentano,  L.,  and  Plauchu,  E.:  La  Gynecologie,  October,  1912,  p.  577. 
'  Lobenstine  and  Harrar:  Bull.  Lying-in  Hosp.,  New  York,  December,  1906. 
'  "Report  of  the  Committee  of  Seven,"  Med.  News,  December  21,  1909. 


SOCIOLOGY  129 

there  were  220,000  venereal  patients  walking  the  streets  of  New  York. 
Holton'  places  this  number  at  200,000.  A  special  committee  of  the 
New  York  ^Medical  Association  recently  placed  the  number  of  venereal 
patients  in  New  York  at  the  same  figure.  The  large  proportion  of 
patients  upon  whom  the  statistics  for  this  report  were  based  were 
males.  Reports  of  23,196  cases  of  venereal  disease  were  made  by  678 
phj'sicians.  It  is  a  significant  fact  that  40  per  cent,  of  all  the  female 
gonorrheics  suffered  from  pelvic  symptoms. 

Gonorrhea  attacking  the  area  below  the  internal  os  frequentlj'  pro- 
duces only  mild  symptoms,  which  are  often  overlooked  by  the  patient 
herself,  and,  as  a  result,  a  definite  proportion  of  such  women  do  not 
go  to  phj'sicians  for  treatment.  In  addition  chronic  gonorrhea  in 
these  localities  is  not  infrequently  overlooked  by  the  average  physician. 
It  is,  therefore,  safe  to  state  that  many  female  gonorrheics  were  over- 
looked. 

In  36  dispensaries  and  charitable  institutions  14,649  cases  of  gon- 
orrhea and  7607  cases  of  syphilis,  a  total  of  22,256  cases,  were  treated 
during  the  year.  In  addition,  there  were  9452  cases  grouped  as  ven- 
ereal in  which,  presumably,  a  positive  diagnosis  had  not  been  made, 
bringing  the  total  to  31,708.  This  does  not  include  3907  cases  of 
chancroid,  898  cases  of  epididymitis,  332  cases  of  cystitis,  414  cases  of 
bubo,  261  cases  of  venereal  warts,  172  cases  of  balanitis  or  phimosis, 
523  cases  of  ophthalmia,  142  cases  of  ophthalmia  neonatorum,  19  cases 
of  vulvovaginitis  in  children,  and  195  cases  of  hereditary  sj^philis. 
Many  cases  of  venereal  disease  are  treated  under  other  names,  since 
some  hospitals  have  rules  forbidding  the  treatment  of  such  cases. 
Statistics  from  a  number  of  large  institutions  were  not  available  to  the 
Committee  of  Seven.  This  Committee  believed  that,  to  obtain  a 
true  estimate  regarding  the  number  of  venereal  patients  in  New  York, 
their  figures  should  l)e  multiplied  by  seven.  Among  4664  women 
treated  at  the  Massachusetts  Cieneral  Hospital  in  1906,  150  had  gon- 
orrhea. These  figures  are,  however,  undouI)tedIy  fallacious,  owing 
to  the  latency  and  chronicity  of  gonorrhea  in  women.  It  would  prob- 
ably be  more  accurate  to  say  that  150  of  these  women  suffered  from 
acute  gonorrhea. 

The  following  statistics,  taken  from  the  Committee  on  Prophylaxis 
of  Venereal  Diseases,  Washington  State  Medical  Association,-  state 
that  80  per  cent,  of  all  men  in  large  cities  have  had  gonorrhea  once  or 
several  times,  45  per  cent,  infect  their  wives,  SO  jx-r  cent,  of  all  opera- 

'  Holton;  .lour.  Amer.  Med.  Assoc,  March  11,  190.5. 

'  (Quoted  by  11.  Guitcras:  Urology,  D.  Appleton  and  Co.,  New  York  and  London,  1012, 
vol.  ii. 


130  GONORRHEA    IN    WOMEN 

tions  upon  women  for  diseases  of  the  uterus  and  adnexa  are  caused  by 
gonorrhea,  and  that  20  per  cent,  of  all  bUndness  results  from  the  same 
cause.  Menge^  states  that  for  every  five  or  six  cases  of  gonorrhea  in 
the  male  there  is  one  in  the  female.  This  observer  bases  his  opinion 
upon  the  fact  that  gonorrhea,  in  the  majority  of  cases,  is  contracted 
through  illicit  intercourse,  and  that  unmarried  men  are  more  licentious 
than  unmarried  women.  On  the  other  hand,  it  should  be  remembered 
that  in  the  male  the  early  symptoms  of  gonorrhea  are  of  such  a  char- 
acter as  to  demand  early  treatment,  and,  as  a  result,  most  cases  are 
cured,  whereas  in  women  the  disease  is  often  so  far  advanced  by  the 
time  severe  subjective  symptoms  arise  that  a  complete  cure  is  often 
extremely  difficult.  Furthermore,  the  chronic  stage  of  the  disease, 
when  confined  to  structures  below  the  internal  os,  is  productive  of  so 
few  symptoms  that  women  frequently  neglect  treatment.  In  women, 
therefore,  the  disease  averages  a  longer  course  than  in  men.  Keyes' 
estimates  that  50  per  cent,  of  young  men  contract  gonorrhea.  Clark' 
places  the  proportion  at  75  per  cent.,  and  Weiss^  at  80  per  cent.  Neis- 
ser^  states  that  75  per  cent,  of  all  men  and  45  per  cent,  of  all  women 
have  had  gonorrhea,  and  that  30  per  cent,  of  the  females  have  been 
infected  by  their  husbands.  Erb^  found  that  48.5  per  cent,  of  all  the 
patients  who  consulted  him  had  suffered  from  gonorrhea.  His  statis- 
tics are  drawn  from  2000  cases.  Bettman  found  that  41  per  cent,  of 
the  patients  in  a  dermatologic  chnic  had,  at  some  time  in  their  lives, 
contracted  gonorrhea.  His  statistics  are  based  upon  241  cases. 
Yudice,  from  similar  material,  found  50  per  cent. ;  Forchheimer'  found 
54.1  per  cent,  among  258  cases,  none  of  whom  were  under  thirty  years 
of  age.  These  included  private  patients.  Cabot*  reports  that  of 
8000  male  patients  questioned  in  a  large  general  hospital,  over  35 
per  cent,  gave  a  history  of  having  had  gonorrhea.  Sanger^  found  230 
cases  (12  per  cent.)  of  gonorrhea  among  1930  women  examined  by  him. 
Bierhoff'"  estimates  that  there  are  in  New  York  today  1,000,000  per- 
sons affected  with  venereal  disease.     Of  this  number,   800,000  are 

'  Menge,  K.:    "Die  Gonorrhoe  des  Weibes,"  Handbuch  der  Gesehleclitskranklieiten, 
Vienna,  1910. 

=  Keyes,  E.  L.:  Diseases  of  the  Genito-urinary  Organs,  1911,  p.  97. 

'  Clark,  J.  B.:  Essays  on  Genito-urinary  Subjects,  New  York,  1912,  p.  51. 

*  Weiss,  L. :  Med.  News,  September  10,  1904,  p.  487. 

'  Neisser:  Quoted  by  Mullowney,  J.  J.:  Tlie  China  Med.  Jour.,  March,  1912. 

•Erb:  Miinch.  mod.  Woch.,  1907,  No.  31. 

'  Forchheimer,  F.:  Boston  Med.  and  Surg.  Jour.,  July  30,  1908,  p.  101. 

'  Cabot:  Boston  Med.  and  Surg.  Jour.,  August  3,  1911. 

»  Sanger:  Die  Tripperansteckung  beim  weiblichen  Geschlcchte,  1889. 

'»  Bierhoff:   New  York  Med.  Jour.,  November  12,  1910. 


SOCIOLOGY  131 

gonorrheics.  Gerrish^  places  the  number  of  venereal  patients  in  New 
York  at  800,000.  Sanger^  believed  that  in  1857  there  were  74,000 
venereal  patients  in  New  York.  The  population  was  at  that  time 
about  700,000.  Morrow'  states  that  venereal  diseases  contribute  a 
sum  total  of  morbidity  of  nearly  double  that  of  all  other  infectious 
diseases,  both  acute  and  chronic.  This  observer  believes  that  there 
are  250,000  married  women  in  the  United  States  infected  with  gon- 
orrhea. He  computes  this  estimate  on  a  basis  of  8  per  cent,  of  in- 
fection among  married  women.  This  proportion  may  be  too  liigh,  as 
Erb,^  in  a  recent  paper,  places  this  figure  at  4.5  per  cent.  The  appar- 
ent discrepanc}^  in  these  figures  may  doubtless  be  partiallj'  accounted 
for  by  the  class  of  patients  from  wliich.  the  statistics  are  compiled. 
Gynecologists  see  more  female  gonorrheics,  and  their  methods  of  ex- 
amination are  more  thorough  than  are  those  of  the  general  practitioner; 
as  a  result,  they  are  likely  to  find  a  greater  proportion  of  infected  pa- 
tients than  those  less  skilled  in  methods  of  examination.  Noeggerath 
estimated  80  per  cent.  Morrow  states  that  there  are  1,500,000  men 
annually  infected  with  gonorrhea"  in  this  country.  Seventy  per  cent, 
of  1155  cases  treated,  mostly  venereal,  at  Hot  Springs,  had  at  the  time 
of  examination,  or  had  previously  had,  gonorrhea.^  Hepburn^  re- 
ports that  in  Baltimore,  during  1906,  3090  cases  of  venereal  disease 
were  treated  by  physicians  in  private  practice,  and  6390  cases  in  dis- 
pensaries. During  the  same  year  there  were  treated  in  Baltimore  575 
cases  of  measles,  1172  cases  of  diphtheria,  577  cases  of  scarlet  fever, 
175  cases  of  chicken-pox,  58  cases  of  smallpox,  and  733  cases  of  tuber- 
culosis, making  a  total  of  3310  cases  of  infectious  disease,  against  a 
total  of  9450  cases  of  venereal  diseases. 

The  frequency  of  gonorrhea  naturally  varies  in  different  walks  of 
life  and  under  different  conditions.  Stephenson''  has  computed  the 
statistics  for  the  following  table : 


CONT>mON 

Number  or  Cases 

Percentage  of 
go.norrhea 

Puerperal  infection 

354 

1,101 

65 

278 

14.763 
18.430 

Married  women  with  fluor  albus 

Loose  women  with  fluor  albus 

26.430 
33.810 

'  Gcrrish:  Soeial  Disea.so.s,  I'Jll,  vol.  ii,  No.  2. 

»  Sanger,  W.  W.:  The  History  of  Prostitution,  1906. 

'.Morrow:  Maryland  Med.  Jour.,  1908,  p.  260. 

*  Erb:  Munch,  mod.  Woch.,  1907,  No.  31.        «  The  Social  Evil  in  ChiouKo,  1911,  p.  298. 

'  Hepburn:  Yale  Med.  .Jour.,  1908,  p.  168. 

'  Stephenson,  S.:  Oplilli.'ilnii:!  Xeonaforum,  I.onclon,  1907,  p.  38. 


132  GONORRHEA    IN    WOMEN 

Luther^  states  that  in  two  large  gynecologic  dispensaries  in  Phila- 
delphia 25  per  cent,  of  the  patients  suffered  from  venereal  disease. 
Bailey^  believes  that  75  per  cent,  of  the  male  and  17  per  cent,  of  the 
female  population  have  at  some  time  had  gonorrhea.  Schwartz'  has 
calculated  that  10  per  cent,  of  married  men  enter  wedlock  afflicted 
with  chronic  gonorrhea,  and  that  an  additional  10  per  cent,  acquire 
gonorrhea  during  married  life.  Some  continental  authorities  compute 
that  75  per  cent,  of  all  male  adults  and  18  per  cent,  of  all  females  have 
suffered  from  gonorrhea.  Ivens*  found  gonorrhea  in  24  per  cent,  of 
his  gynecologic  patients.  Blaschko/ reporting  the  statistics  fi'om  Co- 
penhagen from  1876-95,  finds  that  12.8  per  cent,  of  the  population  have 
gonorrhea.  He  also  found  that,  among  600  students  in  Berlin  in 
1891-92,  18.5  per  cent,  had  gonorrhea,  and  that  20  per  cent,  of  all 
men  are  infected  with  this  disease  once  between  twenty  and  thirty 
years  of  age.  According  to  Emley,*  15  per  cent,  of  all  patients  in  the 
Paris  hospitals,  10  per  cent,  in  all  the  New  York  hospitals,  and  33 
per  cent,  in  all  the  London  hospitals,  have  suffered  from  venereal 
disease.  Swarts'  states  that  70  per  cent,  of  all  women  who  come  to 
New  York  hospitals  for  treatment  of  venereal  diseases  are  reputable 
married  women  who  have  been  infected  by  their  husbands;  that  in 
New  York  there  are  annually  12,500  cases  of  measles,  11,000  cases 
of  diphtheria,  'and  about  19,000  of  tuberculosis — in  round  numbers, 
41,000  cases  of  infectious  disease.  During  the  same  period  there  are 
243,000  cases  of  venereal  disease.  LitchfiekP  estimates  that  in  Berlin 
there  are  annually  infected  with  venereal  disease  4  or  5  per  cent,  of  the 
soldiers,  13  to  30  per  cent,  of  waitresses,  16.5  per  cent,  of  salesmen,  and 
25  per  cent,  of  students.  According  to  the  canvass  completed  in 
April,  1910,  there  are  in  Germany  on  an  average  100,000  persons 
treated  daily  for  venereal  disease.  Of  about  12,000,000  persons  in- 
sured in  the  German  Empire,  about  750,000  are  annually  infected  with 
some  form  of  venereal  disease.  From  data  estimated  by  the  Prussian 
government^  it  has  been  stated  that  at  least  500,000  persons  were  in- 
fected with  a  venereal  disease  yearly.     Another,  and  later,  authority" 

'  Luther,  J.  W.:  The  Pennsylvania  Med.  Jour.,  July,  1912,  p.  192. 

-  Bailey:  Boston  Med.  and  Surg.  Jour.,  June  5,  1902. 

^  Schwartz,  E.,  quoted  by  L.  Weiss:  Second  Annvial  Report  of  the  Committee  ou 
Prophylaxis  of  Venereal  Diseases  of  the  Amer.  Med.  Assoc,  Jour.  Amer.  Med.  Assoc,  June 
30,  1904. 

*  Ivens:   Brit.  Med.  Jour.,  June  19,  1909. 

'Blaschko,  A.:  Syphilis  und  Prostitution  vom  Standpunkte  der  offentliohen  Gesund- 
heitspflege,  Berhn,  1893. 

«  Emley:  Kansas  Med.  Sec,  1908,  p.  428. 

'  Swarts:  Report  of  State  Sanitary  Officers,  1910. 

»  Litchfield:  Jour.  Social  Hygiene,  December,  1909,  p.  174. 

^  Hygienische  Rundschau,  April,  1902. 

'» Quoted  by  Kean,  J.  R.:  Military  Surgeon,  March,  1912,  p.  2.51. 


SOCIOLOGY  133 

places  this  figure  at  773,000.  Of  this  mass  of  statistical  evidence, 
much  of  which  varies  quite  widely,  the  greatest  stress  should  be  placed 
on  the  fig-ures  computed  by  the  Committee  of  Seven  on  Prophylaxis 
of  \'enereal  Diseases  in  New  York.  The  report  of  this  Conunittee 
shows  the  result  of  careful  work,  and  an  entire  absence  of  any  desire 
either  to  overestimate  or  underrate  the  conditions  found. 

-\11  statistics  taken  from  civil  life  are,  however,  for  obvious  reasons, 
more  or  less  inaccurate.  In  the  armj^  and  navy  a  different  condition 
of  affairs  exists.  Here  the  men  are  subject  to  frequent  systematic 
medical  examination,  hence  the  statistics  derived  from  these  sources 
are  undoubtedly  more  reliable.  It  has  been  asserted  that  venereal 
disease  is  more  prevalent  in  the  army  and  navy  than  in  civil  life.  This 
is  probably  not  the  case  if  such  reports  are  compared  with  statistics 
composed  of  men  of  similar  age  in  civilian  life.  Von  Tophy  states 
that  the  relative  venereal  morljiditj-  in  armies  bears  a  close  relation- 
ship to  the  prevalence  of  this  class  of  diseases  among  the  civilians  in 
the  district  in  which  they  are  quartered.  Munson  gives  the  following 
figures  relative  to  the  prevalence  of  venereal  disease  per  1000  in  armies; 

Germany 29.9 

Russia Hli.O 

Japan 40.0 

Holland • 48.0 

France 49.0 

Au.stria-Hungary 60.0 

Great  Britain  (home  statistics) 173.8 

"         "        (foreign       "      ) 522.3 

United  States "3.7 

In  1909  the  rate  of  admission  for  venereal  disease  in  the  following 
armies  was: 

BrilLsh    «7.04 

Austria-Hungary HO. 00 

Frcnc^ 21).0S 

Pru.s.'i.-m  19.0.S 

Bavarian  14.00 

From  the  foregoing  it  will  i)e  seen  that  venereal  diseases  are  ex- 
tremely prevalent  in  the  United  States  army.  For  eighteen  years 
preceding  the  Civil  War  the  morbidity  of  venereal  disease  was  S7.S0 
per  1000.  From  1876  to  1895  inclusive  the  rate  was  82.98,  decreasing 
from  107.6  in  1876  to  73.7  in  1895.  During  this  period  there  was  a 
steady  decrease  in  the  number  of  cases  of  syphilis.  In  decennial  an- 
nual periods  from  1868  to  1897  the  annual  rate  of  syphilis  was  67.20, 
36.45,  and  15.63.  On  the  other  hand,  the  rate  of  gonorrhea,  thotigh 
decrea.sing  up  to  1885,  showed  a  constant  increase  thereafter,  il  being 
37.7(i  in  1SS5  and  56. 21  in  1S'.)7.      In  l!H)l,  in  the  entire  army  (92,4!»1 


134 


GONORRHEA    IN    WOMEN 


men),  there  were  13,911  cases  of  venereal  disease,  equivalent  to  a 
ratio,  on  admission,  of  150.41  per  1000 — for  syphilis,  19.15,  and  for 
gonorrhea,  93.90. 

ADMISSION  RATE  FOR  VENEREAL  DISEASE  IN  THE  ENTIRE  UNITED 
STATES  ARMY 


Year 

VenekealRaie 

Syphilis 

GONORBHEA 

Chancroid 

1899                                        

1900 
1901 
1902 
1903 
1904 
190r,                                       

1906                                       

1907                                       

133.00 
133.97 
150.41 

160.94 
1.-11.4S 
1SS.34 
19S.93 
190.46 
191.62 
194.15 

■  13.98 
15.83 
19.15 
22.37 
23.42 
33.98 
34.34 
28.60 
28.92 
26.40 

80.23 
78.69 
93.90 
106.58 
96.14 
120.97 
131.30 
124.65 
123.30 
135.56 

39.79 
39.45 
37.36 
31.99 
31.92 
33.39 
33.29 
37.21 
44.40 

1908 

32.19 

Total 

Average 

1,698.30 
169.83 

246.99 
24.70 

1.091.32 
109.13 

359.99 
36.00 

ADMISSION  RATE  OF  VENEREAL  DISEASE  IN  THE  ARMY  QUARTERED  IN 
THE  UNITED  STATES 


Yeab 

Venereal  Rate 

Syphilis 

Gonorrhea 

Chancroid 

1899 ' 

127.28 
133.98 
149.96 
161.14 
13;").  84 
163.42 
176.72 
158.91 
167.82 

13.49 
19.62 
19.35 
23.03 
23.64 
28.47 
30.02 
27.28 
25.26 

87.29 
102.42 
104.21 
108.54 

84.09 
107.05 
118.31 
105.21 
107.68 

26.57 

1900 

33  35 

1901 

26.40 

1902 .  . 

29  57 

1903 

28  11 

1904 . .. : 

27.90 

1905 

30.39 

1906 

26.41 

1907 

37.78 

Total 

Average 

1,377.06 
153.01 

210.26 
23.36 

924.80 
102.78 

263.48 
29.28 

Grubbs'  presents  the  following  table,  showing  the  prevalence  of 
venereal  disease  in  the  United  States  army  in  various  localities,  and 
comparing  it  in  frequency  with  the  diseases  next  most  prevalent : 
RATIO  PER  1000  OF  STRENGTH 


Disease 

United  States, 
Including 
Porto  Eico 

Alaska 

Cuba 

Hawaii 

Phiuppine 
Islands 

Venereal  disease  .  . 

167.82 
30.20 

39.39 

55.49 
1.18 

1.18 

152.39 
51.40 

77.55 

223.96 
None 

46.67 

311.22 
167.79 

72.48 

Diarrhea    and    en- 
teritis  

'  Grubbs:   The  Military  Surgeon,  1909,  p.  576. 


SOCIOLOGY 


135 


The  Surgeon  General  of  the  Umted  States  army,  in  his  report  for 
the  year  1904,  states  that  venereal  diseases  held  first  place  in  admis- 
sions to  hospitals,  and  caused  more  discharges  and  rendered  more  men 
non-efficient  than  any  other  single  factor.  During  1904  venereal  dis- 
eases caused  19  per  cent,  of  all  admissions  to  hospital,  15  per  cent,  of 
all  discharges,  and  30  per  cent,  of  all  non-efficiency  because  of  disease. 
Seven  hundred  and  ten  men  were  constantly  on  the  sick  list  for  venereal 
diseases;  a  number  equal  to  the  loss  for  the  entire  year  of  about 
eleven  full  companies  of  infantry. 

TABLE  SHOWING  MOVEMENT  OF  VENEREAL  DISEASE  IN  THE  UNITED 
STATES  NAVY,  1880-1909 


Fiske'  states  that  one  man  in  every  seven  in  the  navy  develops  a 
venereal  infection  each  year.     (Table  by  Kean.-) 

'  Fiske:  Jour.  Amer.  Pub.  Health  Assoc,  Mnroli,  1911,  j).  181, 
'  Kean,  J.  R.;  The  Military  Surgeon,  March,  1912,  p.  2.'>1 


136 


GONORRHEA   IN   WOMEN 


ADMISSION.— TOTAL  VENEREAL  RATIO   PER   1000  OF   MEAN   STRENGTH, 
REGULAR  TROOPS,  UNITED  STATES  ARMY  CASES 


United  States 


Total  Army 


1880. 

1881. 

1882. 

1883. 

1884. 

1885. 

1886. 

1887. 

1888. 
'  1889 . 
'  1890 
» 1891 . 
'1892. 
1 1893 . 
'  1894 . 
1  1895 . 
'  1896 . 
'  1897 . 
1  1898 . 
1 1899 
I  1900 , 

1901. 

1902. 

1903. 

1904 

1905 . 

1906. 

1907. 

1908. 

1909. 

1910. 


75 
SO 
72 
74 
80 
85 
75 
72 
77 
73 
80 
74 
78 
85 
81 
138 
155 
150 
161 
136 
148 
157 
144 
149 
155 
151 
138 


156 
139 
155 
156 
175 
297 
306 
310 
311 
290 
302 
276 


146 
159 
157 
161 
151 
188 
200 
190 
197 
194 
197 
175 


Munson-  states  that  among  all  troops  venereal  diseases  are  al- 
ways more  prevalent  when  on  foreign  service.  He  also  believes  that 
venereal  diseases  are  more  severe  in  tropical  climates,  and  when  sexual 
relations  are  assumed  between  individuals  of  different  races,  the  aliens 
suffering  more  in  this  respect  than  the  resident  population.  In  this 
connection  Kean^  gives  the  following  figures  regarding  the  respective 
races  serving  side  by  side  in  the  Philippine  Islands  for  the  last  quin- 
quennium : 


Year 

White 

Colored 

Filipino 

1905 

306 
309 

277 
267 
290 

None  in  P.  I. 
322 
494 
388 
418 

60.0 
63.2 
63.5 
56.0 
49  0 

1906 

1907 

1908 

1909 

;  Establishment  of  canteen,  February  1,  1889.     February  21,  1901,  Act  of  Congress 
prohibiting  sale  of  alcoholic  drinks  in  canteen. 

2  Munson:    "Camp  Diseases,"  Handbook  of  Medical  Sciences,  Wm.  Wood  and  Co., 
vol.  n. 

'  Kean:  The  Military  Surgeon,  March,  1912,  p.  251. 


SOCIOLOGY 


137 


The  explanation  of  this  astonishing  difference  is  that  the  native 
troops  are  mostly  married,  a  reason  that  probably  applies  also  to  na- 
tive troops  of  other  countries. 

Kerr^  states  that  of  1,281,472  cases  treated  in  the  United  States 
Public  Health  and  Marine-Hospital  Service  between  1886  and  1909, 
263,215,  or  20.5  per  cent.,  were  of  venereal  origin.  The  Surgeon 
General  of  the  United  States  navy,  in  a  recent  report,  states  that 
venereal  diseases  constitute  the  gravest  menace  to  the  physical  ef- 
ficiency in  that  service.  The  five-year  period  from  1904  to  1908,  with 
an  average  of  43,165  men  in  the  navy  and  marine  corps,  shows  a  total 
number  of  admissions  for  venereal  and  genito-urinarj'  disease  of  32,852, 
of  which  number  11,526  were  suffering  from  gonorrhea  and  4890  from 
sj'philis.  The  Surgeon  General  also  states  that  these  figures  are  far 
short  of  the  actual  number,  as  it  was  formerly  the  custom  of  many 
surgeons  to  report  only  such  patients  as  were  incapacitated  by  their 
disease.  In  1909  the  total  primary  admissions  for  all  diseases  were 
38,735,  of  which  number  11,064.  were  venereal  patients.  Gates  be- 
lieves the  prevalence  of  venereal  disease  in  military  service  to  be  about 
the  same  as  that  existing  in  private  life  among  young  umuarried  men. 
Mummery-  reports  that  in  the  British  nav}'  venereal  disease  is  not 
diminishing.  He  states  that  in  1906,  in  a  total  force  of  108,190  men, 
13,193  suffered  from  venereal  disease.  During  the  year  there  was  a 
total  number  of  days'  loss  to  the  service  of  316,631.  The  daily  num- 
ber rendered  inefTicient  because  of  venereal  disease  was  867.46. 

The  table  supplied  by  Lieutenant-Colonel  J.  R.  Kean,^  of  the  Medi- 
cal Department  of  the  United  States  army,  and  Surgeon  C.  N.  Fiske,' 
of  the  United  States  navy,  to  the  Committee  on  Education  of  the 
Public  to  the  Communicability  and  Prevention  of  Syphilis  and  Gon- 
orrhea, shows  the  following  data: 


I'nited  States  army 
United  States  navy 
Japanese  navy 
Briti.sli  navy.  . 
Hritish  army 
Spanish  army 
(lerman  navy . 
Rua-iian  army . 
Austrian  army 
Japanese  army 
Hel((ian  army . 
Duteli  army .  , 
Prussian  army 
Bavarian  army 


13.5.77 
10.5.  U 

f.7.16 
40.70 
28.40 
36.40 
30.20 
28.10 
17.10 
19.9!) 
17.00 
12.20 
10.90 


30.77 
28.23 

17.46 
28.23 
27.84 
i).50 
12.20 
10.10 
10.40 


2.10 
0.97 


30.4.5 
26.29 

37.46 

3.5.10 

11.60 

17.30 

17.70 

16.(K) 

10.10 

6.20 

4,60 

4.40 

3.30 


i<»f'>.(m 

139. 7.5 
122.49 
75.80 
67.80 
63.20 
60.10 
.54.20 
37.60 
26.10 
21.60 
18.70 
15.10 


'  Kerr:  Jour.  Amer.  Pub.  Health  Assoc,  Marrh,  1911,  p.  192. 

'  Mummery:  Brit.  Med.  Jour.,  August  1.5,  1908,  p.  394. 

'K()l)er,  G   M.:   Jour.  Amer.  Pul..  Ih'alth  .Vssoc.  ,\I:inli,  1911,  p 


138 


GONORRHEA    IN   WOMEN 


This  Committee,  in  commenting  on  these  statistics,  states  that,  in 
its  opinion,  the  high  percentage  of  venereal  diseases  occurring  among 
the  Enghsh-speaking  races  is  largely  the  result  of  the  lax  attitude 
adopted  toward  prophylaxis  against  these  diseases  in  both  England 
and  the  United  States. 

Kean^  quotes  the  following  figures  as  the  admission  rates  given  in 
the  reports  last  obtainable  for  the  important  navies  of  the  world : 


Yeab 

Mean  Stbength 

Rate  pes  1000 

German 

French 

Italian 

Japanese.  . 

British 

1907-8 

1905 

1906 

1908 

1909 

1909 

49,955 
49,935 
27,338 
43,857 
112,700 
57,172 

66.0 
75.0 
83.0  = 
167.0 
120.0 
160.0 

Kean'  presents  the  following  tables,  showing  the  prevalence  of 

venereal    disease  in  the    French,   Austro-Hungarian,   Spanish,   and 

Russian  armies: 

FRENCH 


Year 

Gonorehea 

Syphilis 

Chancroid 

Total 

1903 ' 

19.20 

5.90 

1.90 

27.0 

1904. 

21.10 

6.60 

2.10 

29.8 

1905 . 

19.80 

7.00 

2.30 

291 

1906 

19.00 

7.30 

2.30 

28.6 

1907 

18.35 

6.75 

2.73 

27.8 

AUSTRO-HUNGARY 


Year 

Gonorrhea 

Syphilis 

Chancroid 

Total 

1903 

30.1 
31.8 
29.0 
30.1 
28.1 

19.2 
19.3 
20.1 
19.2 
16.0 

9.6 
10.5 
10.9 
11.3 
10.1 

58  9 

1904 .  . 

igo,--. . . 

190t) . 

1907 

61.6 
50.0 
60.6 
54.2 

SPANISH 


Year 

Gonorrhea 

Syphilis 

Chancroid 

Total 

1903 

923.64 
23.05 
20.42 
27.27 
28.41 
38.20 

12.17 
10.43 
9.42 
8.79 
11.64 
13.66 

27.56 
28.65 
27.95 
27.34 
27.84 
40.76 

63.37 
62.13 
57.79 
63.40 
67.89 
92.66 

1904 

1905 

1906 

1907 

1908 ,... 

'  Kean,  J.  R.:  Military  Surgeon,  March,  1912,  p.  261. 
•ci- 'P-^'^  i^  *'^'^  figure  given  in  the  official  reports  for  " Malattie  veneree."     " Malattie 
sifihcho    IS  given  separately,  with  a  rate  of  24  per  1000.     It  is  not  clear,  from  this  context, 
whether  the  latter  should  be  added  to  the  former  or  is  included  in  it. 

'  Kean,  J.  R. :  Loc.  cit. 


SOCIOLOGY 
RUSSIAN  ARMY,  MEAN  STRENGTH,  1,279,051  MEN 


139 


Year 

Total  Veneeeal  Rate 

1904                                                                       

44.7 

1905                                                       

59.2 

1906 

62.7 

1907 

1908 

60.1 
54.3 

Although  the  statistics  from  army  and  navy  reports  refer  only  to 
men,  there  can  be  Uttle  doubt  but  that  they  bear  a  close  relationship 
to  the  prevalence  of  gonorrhea  among  women  in  the  locahties  in  which 
the  troops  are  quartered. 

Source  of  Infection. — The  question  of  the  source  of  infection  is  one 
of  great  importance  to  those  interested  in  the  moral  or  social  prophy- 
laxis of  venereal  diseases.  Numerous  statistics  have  been  compiled, 
and  arguments,  based  on  such  findings,  offered.  In  studying  these 
statistics  it  should  always  be  borne  in  mind  that  in  different  countries, 
and  in  different  periods,  many  different  customs  and  laws  prevail, 
thus  naturally  affecting  the  results  of  such  reports.  Probably  the 
most  accurate  and  recent  statistics  referring  to  the  source  of  infection 
among  gonorrheal  cases  in  this  country  are  those  compiled  by  Bier- 
hoff.'  They  are  computed  from  cases  of  venereal  disease  occurring  in 
New  York,  and  only  those  cases  that  could  accurately  state  the  source 
of  infection  are  included  in  the  tables.  The  diagnosis  in  each  case 
was  based  upon  the  microscopic  or  bactcriologic  demonstration  of  the 
gonococcus: 

TABLE  1.— SOURCE  OF  GONORRHEA  IN  1429  CASES.    MATERIAL  DERIVED 
FROM  PRIVATE  PRACTICE  AND  FROM  THREE  DISPENSARIES 


Pucll;i  publica  (street) 

"  "      (brothel) 

"  "      (kept) 

"  "      (unclassified) 

"  "      (friend) 

_ "  "      (mi.stress) 

Wives  (who  infected  husbands) .  . 

Married  women  and  widows 

Divorc(5es 

Fi!inc<!e 

WorkinRwomen  and  servants.  .  .  . 
Rc.spc(tul)li;  (living  with  parents). 

School-girl.-i 

Sexual  perverts 


First 

Later 

Infection 

Infection 

213 

273 

106 

273 

9 

52 

(> 

18 

20 

22 

4 

0 

21) 

25 

(') 

38 

1 

8 

1 

0 

70 

166 

7 

25 

2 

1 

2 

1 

Total! 


.-)27 


902 


Total 

486 

439 

61 

24 

42 

4 

45 

44 

9 

1 

236 

32 

3 

3 

1,429 


From  t  he  foregoing  it  will  be  seen  that,  in  418  cases,  or  79  per  cent., 
of  all  first  infections,  the  infection  had  its  source  in  a  prostitute. 

'  IJierholT:  New  York  Med.  Jour.,  November  12,  1910. 


140 


GONORRHEA    IN   WOMEN 


TABLE  2.— STATISTICS  COMPILED  FROM  PRIVATE  PATIENTS.— (Bierhoff.) 


Puella  publica  (street 

"  "      (brothelj 

"  "      (kept) .  .    

"  "      (unclassified) .  . 

Wives  (who  infected  husband.sj 

Married  women 

Divorcees 

Widows 

School-girls 

Respectable  (li\'ing  wnth  parents) 
Workingwomen ; 

Actresses 

Servants 

Shop-girls 

Factory  girls . 

Stenographers 

Hair-dressers  -  . 

Manicures .  . 

Authors 

Trained  nurses 

Buyers 

Private  secretaries . 

Cloak  models .  . 

Artist's  models 

MilUners 

Seamstresses 

Business-women 

Cashiers 

Companions .  .  .  > 

Waitresses 

Unclassified 


149 
48 
IS 
9 
26 
8 
3 
0 


53 
3 

8 
0 
6 
0 
3 
2 

3 
4 
2 
3 
2 
5 
3 
1 
1 
1 
1 


191 

56 

24 

14 

27 

9 

5 

1 

26 

56 
5 
9 
1 
7 
1 
3 
2 
3 
4 


Totals. 


462 


578 


From  Table  2  it  will  be  observed  that,  in  private  practice,  370 
cases,  or  64  per  cent.,  of  patients  received  their  infection  from  prosti- 
tutes. Of  a  total  of  1429  cases  of  gonorrhea,  1056,  or  74  per  cent.,  re- 
ceived their  infection  from  public  prostitutes.  The  following  table 
shows  the  results  obtained  by  Fournier  in  Paris  and  Bierhoff  in  Ber- 
lin and  in  New  York  as  to  the  source  of  infection. 


TABLE 

3 

Fournier 
(Paris,  1866) 

Bierhoff 
(Berlin,  1899-1900) 

Bierhoff 
(New  York,  1910) 

12 

44 
138 

126 
41 
26 

0 
0 
0 

26 
9 

10 
0 
0 

1,056 

Clandestine 

Mistresses,  actresses 

Workingwomen 
Servants 

Mistresses,  f     4a 

Actresses     \  57b 

236 

61c 

45d 

Fiancees,     widows,    and    di- 
vorces   

54 

Respectable  women 

School-girls 

32 
3 

Totals 

387 

132 

l,426e 

(»)  Under  prostitute.     {^)  Under  workingwomen.    (<^)  Under  workingwomen.    (^)  Own 
wives,     (c)  Sexual  perverts  not  included. 


SOCIOLOGY  141 

The  report  of  the  Committee  of  Seven  shows  that,  in  cases  in 
which  the  source  of  infection  could  be  traced,  8053  were  from  public 
prostitutes,  whereas  3915  were  from  clandestine  alliances.  The  report 
also  states  that  there  were  988  cases  of  marital  infection,  seemingly 
indicating  that  nearly  33  per  cent,  of  all  venereal  diseases  found  in 
private  practice  among  women  were  communicated  by  the  husband. 
In  certain  quarters  it  is  believed  that  venereal  disease  comes  as  a 
form  of  punishment  for  sin.  Every  year  thousands  of  innocents, 
usually  wives,  are  infected.  Statistics  regarding  venereal  disease  are 
notoriously  inaccurate.  Nevertheless,  such  carefully  computed  re- 
ports as  those  just  quoted  cannot  fail  to  impress  an  unbiased  mind 
with  the  fact  that  the  public  prostitutes  in  the  city  of  New  York 
today  are  by  far  the  most  prolific  disseminators  of  venereal  disease. 

]\Ienge'  states  that  in  Germany,  where  public  prostitutes  are  under 
supervision,  gonorrheal  infection  from  this  source  is  rather  uncommon, 
but  that  the  clandestine  prostitute  is  a  prolific  disseminator  of  the 
di-sease.  Blaschko-  found,  in  lOO  cases  of  gonorrhea  in  the  male,  that 
80  per  cent,  had  contracted  their  infection  from  prostitutes.  Diiring' 
is  of  the  opinion  that  the  prostitute  is  the  most  frequent  source  of 
infection.  Neisser'  states  that  nearly  all  cases  of  gonorrhea  can  be 
ultimately  traced  to  prostitution.  Finger^  and  Lesser^  are  of  a  similar 
opinion. 

General  Prophylaxis. — The  prevalence  and  ravages  of  venereal 
disease  are,  at  the  present  time,  so  great  as  urgently  to  require  the 
grave  consideration  of  every  physician  and  every  student  of  sociology. 

There  is  no  disease  to  which  the  axiom  that  "prevention  is  better 
than  cure  "  applies  more  forcibly  than  to  gonorrhea.  Every  gonorrheic 
is  a  source  of  danger:  a  danger  far  greater  than  accompanies  the  in- 
dividual affected  with  an  ordinary  infectious  disease,  for  the  latter  is 
confined  to  his  hou.se,  if  not  by  the  severity  of  his  disease,  at  least  by 
law,  during  the  period  of  his  infectiousness.  Gonorrheics,  on  the  con- 
trary, mingle  with  their  fellow-men,  and  thus  often  establish  a  sort  of 
endless  chain  of  infection. 

The  pn)])hj'laxis  of  venereal  disease  is  a  subject  thai  is  ;ipproacliod 
by  most  medical  men  w  ith  a  degree  of  repulsion.  Apart  from  the  moral 
aspects  that  immediately  present  themselves,  there  is  a  general  feeling 
that  such  subjects  are  best  not  discussed,  and  that,  under  any  cir- 

'  Mcngp,  K.:   H.andbiich  dor  Gcschlcchtslirankhciten,  Vienna,  I'JIO. 
'  Uliwcliko,  A.:   Syphili.s  und  Prostitution  vom  Standpunkto  dcr  offcnlliclicii  GcsuikI- 
hcitspflr'Kc,  Berlin,  WXi. 

•  During:   Prostitution  und  Gpschlccht.slcrankhpitcn 

•  Ncisiter:  Mittcilungcn  d.  fifspil.schaft  furdie  IkkiinipfuiiKdcrOeschlpclitskrankhcitcn. 
'Finger:   Blennorrlioe  dcr  Spxualorgan.  '  Lesser;  Cliarit(5  Vortriige. 


142  GONORRHEA    IN   WOMEN 

cumstances,  venereal  disease  affects  chiefly  the  guilty.  This  view  is 
particularly  prevalent  among  the  English-speaking  races.  As  a  con- 
sequence we  have,  in  this  country,  the  sorry  spectacle  of  our  boards  of 
health  ignoring  a  large  and  important  group  of  diseases  that  are  well 
known  to  be  contagious  and  a  menace  to  public  and  private  health, 
and  well  recognized  as  one  of  the  most  potent  factors  in  the  production 
of  race  suicide.  The  explanation  for  this  laxity  will  probably  be  found 
to  rest  on  the  difficult  moral  problems  presented  in  this  field  of  prophy- 
laxis, and  on  the  absence  of  any  certain  specific  method  that  would 
offer  fair  prospects  of  success.  The  double  standard  of  morals  is  a 
strong  factor  in  the  production  of  venereal  disease,  but  as  the  woman, 
in  the  event  of  pregnancy  occurring,  will  always  be  the  one  to  bear  the 
outward  and  visible  signs  of  her  unchastity,  there  seems  little  likeli- 
hood of  a  change  taking  place  in  this  respect. 

■  The  subject  of  the  prevention  of  venereal  disease  may  be  grouped 
under  three  broad  headings:  (1)  General  prophylaxis  for  those  not  in- 
fected ;  (2)  the  method  of  dealing  with  prostitution ;  and  (3)  the  method 
of  dealing  with  those  already  infected.  There  can  be  no  doubt  in  the 
minds  of  all  thinking  persons  that  of  all  methods  of  dealing  with  this 
difficult  and  urgent  problem,  education  offers  the  best,  broadest,  and 
most  hopeful  n:ieans  of  securing  eventual  success.  Owing  to  the  secret 
nature  of  venereal  disease,  this  can  best  be  accomplished  in  the  hands 
of  a  broad-minded  educational  board,  such,  for  example,  as  the  Ameri- 
can Medical  Association.  The  prevalence  and  ravages  of  venereal 
disease  are  not  known  to  the  general  lay  pubUc,  in  whose  minds  this 
group  of  diseases,  and  gonorrhea  especially,  is  often  regarded  as  a  com- 
paratively mild  lesion.  If  their  extent  and  harmful  influence  were 
generahy  recognized,  a  great  step  in  advance  in  dealing  with  these  con- 
ditions would  be  made,  and  the  physician  sought  more  readily  for  in- 
struction and  aid.  Christian,'  in  a  recent  paper  read  before  the 
Section  on  Surgery  of  the  Medical  Society  of  the  State  of  Pennsylvania, 
rather  questions  the  advantages  to  be  derived  from  this  form  of  prophy- 
laxis. One  example  will  be  suflScient  to  prove  the  fallacy  of  such  a 
view.  Few,  if  any,  men  would  have  intercoiirse  with  a  woman  known 
to  have  gonorrhea  or  syphilis.  Statistics  have  amply  demonstrated 
that  a  large  proportion  of  pubHc  prostitutes  are  affected  with  a  venereal 
disease  of  some  kind.  It  would  be  conservative  to  state  that  50  per 
cent,  of  all  public  prostitutes  in  the  United  States  were  the  incumbents 
of  an  uncured  venereal  disease.  The  majority  of  these  are  chronic 
cases,  and  do  not  by  any  means  always  transmit  their  infection  to 
their  partners.     Nevertheless,  few  individuals  would  care  to  jeopardize 

'  Christian,  H.  M.:  The  Pennsylvania  Med.  Jour.,  July,  1912,  p.  788. 


SOCIOLOGY  143 

themselves  were  they  truly  cognizant  of  the  fact  that  one  out  of  every 
two  inmates  of  houses  of  ill-fame  was  affected  with  a  communicable 
disease.  Too  often  such  information  is  considered  by  men  as  ema- 
nating from  a  moral,  rather  than  an  actual,  cause,  and  it  is  believed  to 
be  an  exaggeration,  and,  therefore,  is  disregarded.  Bigelow^  writes 
that  sex  education  will  not  enforce  universal  morality  in  conformity 
with  our  accepted  code,  but  it  will  help  in  many  decisive  battles  with 
sex  instinct.  To  all  those  who  see  nothing  in  the  movement  because 
it  will  not  solve  all  the  sex  problems  that  have  created  a  demand  for 
special  instruction,  he  replies  by  pointing  out  that  general  education 
makes  more  efficient  and  better  citizens,  but  also  often  fails. 

The  age  of  consent  is  an  important  matter  in  the  prophylaxis  of 
venereal  disease.  In  many  States  the  fixed  age  is  too  young.  In 
Georgia  and  Mississippi  the  age  of  consent  is  ten  years;  in  7  other 
States  it  is  fourteen  years;  in  Texas,  it  is  fifteen  years;  in  Illinois  and 
in  21  other  States,  it  is  sixteen  years — thus  the  average  age  of  consent 
in  32  states  is  sixteen  years  or  un,der.  All  high  school  children  should 
receive  instruction  regarding  venereal  disease;  in  many  States  this 
is  now  included  under  the  heading  of  general  hygiene.  With  a  little 
circumspection  such  instruction  can  be  shorn  of  all  objectionable 
features.  The  exact  age  at  which  children  should  receive  this  instruc- 
tion is  a  point  to  be  carefully  considered. 

Boys  of  thirteen  or  fourteen  and  girls  a  year  or  two  older  should 
certainly  have  some  knowledge  of  sex  hygiene,  and  it  would  be  a 
distinct  advantage  for  them  to  obtain  such  knowledge  from  a  reliable 
source,  rather  than  to  depend  on  the  present  method  of  obtaining  a 
scattered  and  distorted  view  from  older  children  or  even  more  harmful 
sources.  It  is  proba})le  that  such  institutions  as  the  Red  Cross  Society 
in  this  country,  and  the  First  Aid  Instruction  in  England,  could  be 
utilized  with  advantage  to  teach  children  the  necessary  facts  regarding 
venereal  disease.  Lectures  to  boys  and  girls  should,  of  course,  be 
given  separately,  the  boys  receiving  their  instruction  from  a  male  and 
the  girls  from  a  female  teacher.  Such  work  has  already  been  begun 
in  this  country.  Morrow^  states  that  a  collective  investigation  which 
is  now  in  progress,  but  not  yet  completed,  undertaken  by  a  committee 
of  the  National  Educational  Association,  shows  that,  in  138  schools 
and  colleges  in  the  United  States,  personal  and  sex  hygiene  is  taught 
systematically. 

Education  along  broad  lines  could  also  be  given  as  a  part  of  each 
college  curriculum.     In  this  connection  it  is  interesting  to  observe  that 

'  Uigclow,  M.  E.:  Jour.  Amer.  Med.  Assoc,  October  .5,  1912,  p.  1312. 
2  Morrdw,  P.  A.:  New  York  Med.  Jour.,  March  23,  1912,  p.  577. 


144  GONORRHEA    IN    WOMEN 

this  step  has  already  been  taken  in  Austria.  Some  years  ago  the 
students,  on  entering  an  Austrian  university  for  the  first  time,  were 
handed  a  leaflet  containing,  in  clear  and  instructive  language,  warnings 
against  imprudence  in  sexual  intercourse,  and  explaining  the  dangers 
of  gonorrhea  and  syphilis,  both  to  the  affected  subject  and  to  the  wife 
and  offspring.  The  next  step  in  advance  consisted  in  the  instruction 
of  the  student  before  he  entered  the  university.  In  the  higher  classes 
of  the  preparatory  schools,  in  which  the  pupils  were  between  sixteen  and 
eighteen  years  of  age,  teaching  of  anatomy  gave  a  good  opportunity 
for  scientific  instruction  on  this  point.  At  present  the  instruction  on 
sexual  subjects  is  given  by  the  school  physician,  who  uses  his  discretion 
as  to  age  at  which  it  shall  be  begun.  As  a  rule,  such  instruction  is 
given  when  the  pupils  are  about  fourteen  years  of  age. 

Lectures,  preferably  illustrated  by  lantern-slides,  should  be  delivered 
to  various  business  and  workingmen's  associations,  unions,  and  large 
industrial  institutions.  Great  care  should  be  exercised  to  have  such 
lectures  free  from  all  moral  teaching  and  the  expression  of  virtuous 
platitudes.  The  audience  should  be  told  that  continence  is  entirely 
compatible  with  health,  and  the  dangers  and  prevalence  of  venereal 
disease  should  be  dwelt  upon.  The  Young  Men's  Christian  Associa- 
tion would  be .  a  vehicle  of  great  aid  in  the  advancement  of  such  an 
educational  cause.  If  a  campaign  of  this  kind  were  waged  by  some 
world-wide  educational  body,  such  as,  for  example,  the  American 
Medical  Association,  various  periodicals  could  be  utilized,  and  would 
be  of  the  utmost  benefit  as  disseminators  of  knowledge.  Personal 
hygiene,  exercise,  and  cleanliness  should  be  encouraged.  There  is  no 
doubt  that  a  certain  class  of  modern  literature  and  art,  together  with 
questionable  plays,  form  a  very  decided  detrimental  factor  in  personal 
morality.  The  Board  of  Censors  recently  instituted  in  England  is 
doing  good  work  along  this  line.  That  the  importance  of  sexual 
education  is  recognized  in  Germany  is  instanced  by  the  prominence 
given  to  this  subject  in  the  Internationale  Hygiene  Ausstellung  in 
Dresden,  of  1911. 

The  interminghng  of  the  sexes  as  the  result  of  the  modern  trend  of 
business  life  is  detrimental  to  the  morality  of  women.  Other  impor- 
tant factors  tending  toward  sexual  impurity,  and  therefore  toward  the 
propagation  of  venereal  disease,  are  certain  economic  problems — ■ 
the  influence  of  crowding,  labor  competition,  faulty  home  environ- 
ment, migration  to  cities,  child  labor,  ignorance,  and  inadequate 
moral  training.  The  advertising  of  unlicensed  practitioners  of  medi- 
cine, the  patent  medicines,  the  baby-farms,  massage  establishments, 
and  the  abortionists,  all  have  an  undermining  influence  on  pubUc 


SOCIOLOGY  145 

morals.  All  these  factors  must  be  taken  into  consideration  in  attempt- 
ing to  reduce  the  prevalence  of  venereal  disease.  Many  of  these  are 
insignificant  in  themselves,  but  when  taken  together,  are  of  the  utmost 
importance.  Sane  educational  pamphlets  are  also  of  value  in  teaching 
the  public  the  dangers  of  venereal  disease.  The  educational  problem 
is  so  large  a  one  that  it  could  be  handled  with  any  degree  of  effective- 
ness only  by  the  appointment,  bj^  some  leading  body,  of  a  number  of 
committees.  Wolbast^  has  suggested  a  Committee  on  High  Schools, 
a  Committee  on  Workingmen  and  Women's  Labor  Unions,  and  Uke 
organizations,  a  Committee  on  Army  and  Navy,  a  Committee  on  Shops 
and  Factories,  a  Committee  on  Churches  and  Religious  Bodies,  a 
Committee  on  Young  People's  Clubs  and  Settlement  Houses,  and  a 
Committee  on  Fraternal  Orders.  Such  committees  could  undoubtedly 
do  much  good.  We  think,  however,  that  the  army  and  navy  are  quite 
competent  to  handle  their  own  affairs.  A  Committee  on  Publi- 
cation would,  without  doubt,  be  of  great  advantage.  Phj^sicians 
could  also  become  valuable  disseminators  of  knowledge.  Since  the 
organization,  in  February,  1905,  of  the  American  Society  of  Sanitary 
and  Moral  Prophylaxis,  much  praiseworthy  work  along  educational 
lines  has  been  accomplished,  a  detailed  description  of  which  is  given  by 
Morrow.-  Branch  societies  have  been  established  in  Philadelphia, 
Detroit,  Chicago,  Milwaukee,  Jacksonville,  Indianapolis,  Baltimore, 
St.  Louis,  Spokane,  Portland,  Denver,  and  many  other  cities.  In 
Germany  the  Association  for  the  Prevention  of  Venereal  Disease,  of 
which  Professor  Neisser  is  the  President,  has  accomplished  much  good 
in  this  way.  This  society  numbers  over  5000  members,  and  has 
distributed  over  5,000,000  pamphlets.  National  organizations  for 
the  prevention  of  venereal  disease  also  exist  in  France,  Austria,  Den- 
mark, Italy,  Hungary,  and  Belgium.  The  oldest  organization  is  the 
Teleia  (literally  translated,  meaning  "Venus"),  of  Budapest,  which 
is  fifteen  years  old.  Sweden  has  no  organization,  but  the  physicians 
have  accomplished  much  in  the  way  of  education  by  the  distribution 
of  pamphlets.  It  has  been  claimed  by  the  opponents  of  educational 
prophylaxis  that  it  is  ineflicient,  and  the  statement  has  been  made  that 
venereal  tlisease  is  prevalent  among  medical  students,  a  class  of  young 
men  who  are  comparatively  well  educated  regarding  venereal  disease. 
No  proof  has,  however,  been  adduced  to  show  that  this  is  so.  As  a 
matter  of  fact,  venereal  disease  among  medical  students  is  compara- 
tively infrequent,  and  even  if  it  were  not,  this  would  be  no  argument 
against  education.     The  history  of  medicine  shows  that  all  great  steps 

'  Wolbast:   Me<l.  und  Surg.  Jour.,  September  V.i,  190H,  p.  280. 
'  Morrow,  P.  A.:   New  York  Med.  Jour.,  March  23,  1912,  p.  577. 
10 


146  GONORRHEA    IN    WOMEN 

in  the  prophylaxis  against  disease  have  been  accomplished  along 
educational  lines.  As  examples  of  this  may  be  mentioned  tuberculosis 
and  yellow  fever.  Perhaps,  however,  the  greatest  cause  of  lapse  from 
virtue  on  the  part  of  the  average  young  man  or  woman  is  alcohol, 
and  the  law  regarding  the  selling  of  this  to  ndnors  should  be  strictly 
enforced.  It  is  a  well-known  fact  that  a  large  proportion  of  men  are 
under  the  influence  of  alcohol  when  they  become  infected.  Alcohol 
in  any  form,  and  especially  in  the  young,  tends  to  weaken  the  moral 
fiber,  to  break  down  natural  restraints  and  barriers,  and  to  cause 
forgetfulness  or  disregard  of  the  dangers  of  illicit  intercourse.  The 
cafes  and  saloons  that  cater  to  this  class  of  trade  should  receive  rigid 
supervision,  and  any  infringement  of  the  present  law  should  be  severely 
dealt  with.  These  places — and  they  are  numerous  in  all  large  cities 
— are  direct  factors  in  the  production  of  inestimable  harm  and  the 
ruin  of  many  young  girls.  The  Chicago  Vice  Commission,^  in  its 
recent  report,  strongly  recommends  rigorous  supervision  of  all  such 
resorts.  An  excellent  movement  is  now  being  made  in  some  States  to 
teach  public  school-children  the  evils  of  alcohol. 

The  frequency  with  which  gonorrhea  is  contracted  by  intoxicated 
individuals  is  well  known.  Moller-  gives  some  interesting  data  on  this 
subject.  He  questioned  661  patients  concerning  the  source  of  their 
infection.  At 'least  20  per  cent,  of  the  number  gave  information 
sufficiently  clear  to  make  investigation  of  the  source  possible;  67  per 
cent,  could  give  no  information,  having  been  intoxicated  at  the  time  of 
infection. 

Although  infection  by  means  other  than  sexual  intercourse  is  rare 
in  any  form  of  venereal  disease,  and  especially  is  this  so  of  gonorrhea, 
nevertheless  steps  should  be  taken  to  see  that  public  lavatories  be  so 
constructed  and  cared  for  that  the  likelihood  of  transmitting  contagion 
would  be  reduced  to  the  minimum.  The  fact  should  never  be  lost 
sight  of  that  it  is  the  young  who  are  most  likely  to  become  infected. 
Thus,  LePileur  states  that,  of  718  women  affected  with  venereal  disease, 
62.9  per  cent,  were  between  sixteen  and  twenty  years  of  age  at  the  time 
of  infection.  Storer^  found,  of  140  single  women  suffering  from 
venereal  disease  who  applied  for  dispensary  treatment,  only  14  were 
over  thirty  years  of  age,  while  62  per  cent,  were  between  seventeen  and 
twenty-two  years  old.  Among  married  women,  the  average  age  was 
somewhat  greater. 

'  Social  Evil  in  Chicago,  Report  of  the  Vice  Commission,  1911. 

'  Moller,  M.:  Zeitschr.  f  Bekampf.  d.  Geschlechtskrankh.,  Leipzig,  vol.  v,  part  7. 

'  Storer:  Amer.  Jour.  Pub.  Hygiene,  190S,  p.  52. 


J 


SOCIOLOGY  147 

In  1910  the  Committee  on  Education  of  the  Public  as  to  the  Com- 
municabiUty  and  Prevention  of  Gonorrhea  and  Syphihs  reported  at  the 
thirty-eighth  annual  meeting  of  The  American  Public  Health  Associa- 
tion, and  presented  the  following  suggestions:  The  Committee  recom- 
mended: (1)  The  recognition,  studj-,  and  control  of  the  prevalence  of 
these,  as  with  other  communicable  diseases;  (2)  an  educational  cam- 
paign for  parents  and  children,  the  teaching  to  be  strictlj'  medical 
(non-moral) — (a)  Pamphlets;  (b)  utilization  of  State  Health  Depart- 
ment; (c)  State  Health  Department  to  make  effort  to  awaken  interest 
in  venereal  disease  among  phj-sicians;  (d)  State  Health  Department  to 
send  out  paid  and  trained  lecturers  to  address  special  meetings  of 
parents,  health  officers,  medical  men,  teachers,  and  others  in  schools, 
colleges,  churches,  etc.,  on  these  and  other  preventable  diseases;  (e) 
State  Health  Department  to  encourage  the  organization  of  associa- 
tions for  prophylaxis;  (J)  health  departments  to  interest  and  provide 
for  authorities  having  charge  of  educational  curriculum  in  public  and 
private  schools — (1)  By  the  introduction  of  biology  into  the  graded 
courses  of  all  schools;  (2)  to  provide  instruction  in  sexual  matters  for 
students  of  the  upper  grades;  (3)  by  special  instruction  to  students 
who  are  to  become  instructors.  To  impress  upon  presidents,  deans, 
preceptors,  and  teachers  the  necessity  of  exercising  their  influence  on 
students  in  reference  to  the  communicability  of  gonorrhea  and  syphihs, 
and  to  inculcate  a  morale  of  protection  among  college  fraternities;  (g) 
to  utilize  the  public  press  for  the  proper  occasional  presentation 
of  the  subject,  and  to  discourage  the  display  of  advertising  matter 
that  encourages  the  exposure  to  these  diseases;  (h)  to  utilize 
church  clubs,  and  especially  mothers'  clubs,  for  the  instruction  of 
parents;  (i)  health  departments  to  recommend  the  enactment  of 
laws  for — (1)  Physical  inspection  and  segregation  of  prostitutes;  (2) 
notification  and  report  (by  number,  if  desired)  of  venereal  disease; 
(3)  physical  examination  of  men  before  marriage,  male  applicants  for 
marriage  licenses  being  required  to  submit  to  examination  by  a  duly 
qualified  physician  for  the  purpose  of  ascertaining  whether  said 
applicants  are  free  from  venereal  disease;  (4)  to  make  it  a  crime  to 
spread  venereal  disease;  (5)  keeping  open  free  night  dispensaries 
and  maintaining  special  dispensaries  and  hospitals  for  the  treatment 
of  the.se  diseases;  (6)  advocacy  of  temperance  on  account  of  the  rela- 
tionship existing  between  alcoholism  aiul  venereal  diseases;  (k) 
advocacy  of  personal  cleanliness  and  venereal  prophylaxis;  {I) 
advocacy  of  early  marriage.     These  recoimnendations  were  adopted. 


148  GONORRHEA   IN   WOMEN 


REFERENCES 

1.  Bierhoff:  New  York  Med.  Jour.,  November  12,  1910. 

2.  Clock:  Amer.  Jour.  Dermat.,  1907,  p.  487. 

3.  Doleris:  La  Gynecologie,  November,  1910. 

4.  Emley:  Kansas  Med.  Society,  1908,  p.  428. 

5.  Fiske:  Jour.  Amer.  Pub.  Health  Assoc,  March,  1911,  p.  181. 

6.  Forchheimer:  Bost.  Med.  and  Surg.  Jour.,  July  30,  1910,  p.  161. 

7.  Grubbs:  Military  Surgeon,  1909,  p.  576. 

8.  Kerr:  Jour.  Amer.  Pub.  Health  Assoc,  March,  1911,  p.  192. 

9.  Hepburn;  Yale  Med.  Jour.,  1908,  p.  168. 

10.  Hoff:   Military  Surgeon,  1909,  p.  732. 

11.  Holton:  Jour.  Amer.  Med.  As.soc.,  March  11,  1905. 

12.  Johnson,  J.  T.:  Jour.  Amer.  Med.  Assoc,  March  11,  1905. 

13.  Litclifield:   Jour.  Social  Hygiene,  December,  1909,  p.  174;   Jour.  Amer.  Med.  Assoc, 

February  26,  1910. 

14.  Morrow:  Maryland  Med.  Jour.,  1908,  p.  260. 

15.  IMummery:  Brit.  Med.  Jour.,  August  15,  1908,  p.  394. 

16.  Munson:   MiUtary  Hygiene,  p.  823. 

17.  Robb:  Trans.  Amer.  Gyn.  Soc,  1906. 

18.  Sanger:  Hist,  of  Prostitution. 

19.  Social  Evil  in  Chicago:  Report  of  the  Vice  Commission,  1911. 

20.  Storer:  Amer.  Jour.  Pubhc  Hygiene,  1908,  p.  52. 

21.  VonTophy:  Military  Hygiene,  p.  830. 

22.  Wolbast:  Med.  and  Surg.  Jour.,  September  13,  1908,  p.  280. 

23.  Amer.  Jour.  PubUc  Hygiene,  1908,  p.  39. 

24.  Report  Com.  State  Board  of  Hygiene,  Washington,  1905 

25.  Report  of  the  American  Public  Health  Association,  thirty-eighth  annual  meeting,  in 
the  Jour  Amer.  Pub.  Health  Assoc,  March,  1911,  p.  162. 

26.  Report  of  the  Committee  of  Seven,  Med.  News,  December  21,  1909. 


CHAPTER  VI 
PROSTITUTION 

The  history  of  prostitution  can  be  traced  back  to  the  earliest 
traditions  of  the  human  race.  Moses  attempted  to  eradicate  prostitu- 
tion, but  without  success.  Among  the  early  Greeks  and  Romans 
prostitution  was  rife.  As  we  follow  the  progress  of  time  among  the 
peoples  of  the  world,  so  can  the  history  of  prostitution  be  followed  from 
age  to  age.  As  surely  as  a  community  of  any  size  is  gathered  together 
in  a  given  locality,  as  surely  will  prostitution  make  its  appearance. 
The  number  of  prostitutes  per  thousand  of  the  population  varies  with 
different  races  and  at  different  times.  It  bears,  however,  always  a 
direct  relationship  to  the  number  of  able-bodied  unmarried  men  in  any 
given  community. 

Although  Flatau^  and  others  have  amply  proved  that  continence 
is  entirely  compatible  with  health,  it  is,  nevertheless,  impossible 
to  formulate  laws  that  will  eradicate  or  even  control  sexual  desire — 
one  of  the  strongest  if  not  the  strongest  instinct  of  the  human  race. 
Often  more  powerful  than  the  instinct  of  self-preservation,  the 
sexual  appetite  may  be  provocative  both  of  inestimable  good  and  of 
much  harm.  Were  it  not  for  this  passion,  the  world  would  quickly  be 
depopulated;  on  the  other  hand,  just  as  certainly,  a  very  definite 
proportion  of  sorrow  and  crime  can  be  laid  at  its  door.  As  a  result  of 
many  economic  and  social  factors,  "there  has  arisen  in  society  a  figure 
which  is  certainly  the  most  mournful,  and  in  some  respects  the  most 
awful,  upon  which  the  eye  of  the  moralist  can  dwell.  That  unhappy 
being  whose  very  name  it  is  a  shame  to  speak ;  who  counterfeits,  with 
a  cold  heart,  the  transports  of  affection,  and  submits  herself  as  the 
passive  instrument  of  lust;  who  is  scorned  and  insulted  by  the  vilest 
of  her  sex,  and  doomed,  for  the  most  part,  to  disease  and  abject 
wretchedness  and  an  early  death,  appears  in  every  age  as  the  perpetual 
symbol  of  the  degradation  and  sinfulness  of  man.  Herself  the  supreme 
type  of  vice,  she  is  ultiinatcij^  the  most  officicMit  guardian  of  virtue. 
But  for  her,  the  unchallenged  jiurit}'  of  countless  hapjiy  homes  would 
bo  polluted,  and  not  a  few  who,  in  the  pride  of  tlieir  unt  empted  chastity, 
think  of  her  with  an  indignant  shudder,  would  have  known  tiie  agony  of 

'  Flaluu,  G.:  Scxucllc  Ncurastlicnic,  Berlin. 
149 


150 


GONORRHEA    IN    WOMEN 


remorse  and  despair.  On  that  one  degraded  and  ignorant  form 
are  concentrated  the  passions  that  might  have  filled  the  world  with 
shame.  She  remains,  while  creeds  and  civilization  rise  and  fall,  the 
eternal  'priestess  of  humanity,'  blasted  for  the  sins  of  the  people" 
(Leckyi). 

The  relation  that  prostitution  bears  to  gonorrhea  needs  no  confir- 
mation. Huber,-  in  the  routine  examination  of  533  sick  and  well 
prostitutes,  found  that  59.6  per  cent,  had  gonorrhea.  Prowe^  detected 
gonorrhea  in  76.9  per  cent,  of  a  series  of  prostitutes  examined  in  San 
Salvador,  Central  America.  While  Dreier  and  SlachoW  found  positive 
proof  of  gonorrhea  in  220  of  1021  inscribed  prostitutes,  and  a  suspicion 
of  the  disease  in  94  additional  women.  Bendig=  presents  the  following 
statistics  showing  the  frequency  of  venereal  diseases  among  prostitutes 
of  certain  cities  of  Germany: 


_                         Population, 
"-'"'                    Last  Censds 

Ndmber  of 
Prostitutes 

Control 

Found 
Diseased 
(Venereal  Dis- 
eases Found) 

Arrested 

Prostitutes 

not  under 

Control 

Found 
Diseased 

Berlin 2,040,222 

Hamburg 809,090 

Munich ;'        538,-393 

Drestlen 514,283 

Cologne 428,503 

Frankfurt  a.  M. .  .  .         334.951 
Hanover ,        250,632 

Stuttgart '        249,286 

Chemnitz 244,405 

Charlottenburg  .  . .         239,512 

3,692 
920 

175 
281 
1,116 
512 
210 

22 

76 

122 

733 
791 

36 
426 
672 
493 
182 

28     ^ 

80 

16 

2,658 
1,388 

Not  given 

602 
About  700 

680 

378 

500  to  700 
annually 

300  to  350 
annually 
524 

475 

20  per 

cent. 

207 

93 

232 

214 

80  per 

cent. 

158 

123 

8 

There  is  every  reason  to  believe  that  gonorrhea  is  extremelj^  prev- 
alent in  the  prostitutes  of  the  United  States,  although,  on  account  of 
our  methods  of  dealing  with  this  subject  in  this  comitry,  no  accurate 
data  are  obtainable. 

As  Lawrence  F.  Flick  has  well  said,  in  approaching  the  subject  of 
prophylaxis  of  venereal  disease,  we  should  separate  the  moral  from  the 
sanitary  side.  It  is  sheer  absurdity  to  assert  that  prostitution  can 
ever  be  completely  eradicated.  The  sexually  frigid  or  superannuated 
may  attempt  to  make  laws  aiming  to  govern  the  hot  blood  of  youth, 

'  Lecky:  History  of  European  Morals. 
=  Huber:  Wien.  med.  Wochenschr.,  1898,  p.  24. 
'  Prowe:  Cent.  f.  Gyn.,  1901,  vol.  xxv,  p.  82. 

'  Dreier  and  Slachow:   Die  Prostitution,  Bremen,  in  Hygienischer  Beziehung,  1907. 
'  Bendig:  Zeitschrift  fur  die  Bekampfung  der  Geschlechtskrankheiten,  vol.  xxii.  No.  1; 
also  Bierhoff,  P.:  New  York  Med.  Jour.,  November  16,  1912,  p.  1010. 


I 


PROSTITUTION  151 

but  such  laws  can  never  be  enforced.  The  question  of  prostitution 
is  one  governed  largely  by  the  great  law  of  supply  and  demand. 
The  high  cost  of  living  is  undoubtedly  an  important  factor  to  be  con- 
sidered in  studying  the  question  of  prostitution  at  the  present  day. 
Too  often  the  increased  cost  of  living  precludes  or  postpones  marriage, 
and  leaves  in  everj^  city  a  large  number  of  healthy  individuals  of  both 
sexes  whose  normal  and  not  infrequently  excessive  sexual  desires  have 
no  legitimate  outlet.  There  can  be  no  argument  regarding  the 
existence  of  prostitution.  It  is  estimated  that  in  New  York  today 
there  are  between  50,000  and  75,000  prostitutes,  and  that  $125,000,000 
is  spent  annually  by  the  population  of  the  civilized  world  for  illicit 
sexual  congress. 

Kelly'  estimates  that  venereal  diseases  cost  America  three  billion 
dollars  a  year.  These  figures  seem  to  be  underestimated,  rather  than 
exaggerated.  In  the  report  of  the  recent  Chicago  Vice  Commission 
it  is  estimated  that  the  profits  accruing  from  prostitution  in  that  city 
alone  amount  to  $15,000,000  annually.  The  important  question  to 
decide  is,  What  attitude  shall  be  taken  toward  prostitution  bj^  those 
interested  in  the  suppression  of  venereal  disease?  In  deciding  this 
question  many  important  details  must  be  considered.  The  Committee 
of  Fifteen  recommended — (a)  That  prostitution  must  be  driven  out  of 
tenements  and  apartment  houses  and  excluded  from  the  houses  of  the 
poor;  (h)  that  it  must  not  be  segregated,  for  such  localities  become 
areas  of  crime;  (c)  that  all  public  manifestation  of  prostitution  must 
be  suppressed.  There  can  be  no  question  as  to  the  expediency  of  the 
foregoing  suggestions,  w'ith  the  one  exception  perhaps  of  the  second. 
The  belief  that  prostitution  can  ever  be  entirely  abolished  is  Utopian. 
From  time  immemorial  attempts  have  been  made  in  many  countries 
to  eradicate  it,  but  always  without  success,  as  witness  the  following 
instance:  Many  years  ago,  when  Philadelphia  was  a  factor  in  the 
shipping  industry,  the  better  class  of  citizens  rose  up  against  this  evil, 
and  brought  their  influence  to  bear  on  the  police  department,  so  that 
the  closure  of  all,  or  nearly  all,  the  houses  of  prostitution  was  effected. 
It  was  not  long,  however,  before  a  petition  was  laid  before  the  city 
fathers  asking  that  the  severity  of  the  police  cf)ntr()l  be  relaxed,  since 
it  became  unsafe  for  respectable  women  to  walk  the  streets.-  In  1G07 
Berlin  closed  all  the  brothels  within  the  city,  but  was  forced  to  reopen 
them.  Similar  failures  followed  efforts  in  France,  in  15G0,  in  England 
under  the  reign  of  Henry  VIII,  and  later  in  Australia.  In  Pittsburgh, 
in  ISOl,  an  attempt  was  made  to  close  all  houses  of  prostitution,  but 

'  Kelly,  II.  A.;  .lour.  Amer.  .Med.  Assoc,  October  0,  1912,  p.  i:n2. 
-  'Pile  .iiilliiir  (Hicslioiis  I  lie  vcnicily  of  the  liiltcr  .statcinciil. 


152  GONORRHEA    IN    WOMEN 

this  failed.  A  year  later,  in  New  York,  a  similar  effort  was  made, 
with  the  result  that  vice  was  disseminated  throughout  the  city. 
Nearly  every  city  of  any  size  in  the  United  States  has  at  times 
been  swept  by  waves  of  moral  virtue  that  have  resulted  in  crusades 
against  the  so-called  "social  evil."  How  useless,  and  often  actually 
detrimental,  such  efforts  have  always  proved  is  a  fact  well  known  to 
students  of  sociology  and  those  interested  in  the  prophylaxis  of 
venereal  disease. 

As  has  previously  been  stated,  much  diversity  of  opinion  exists  as  to 
the  best  methods  of  handling  the  difficult  problem  of  prostitution.  In 
this  connection,  however,  it  is  interesting  to  observe  the  unity  of  opin- 
ion that  exists  in  the  recent  reports  issued  by  the  Police  Commissioner 
of  Boston,  the  Committee  of  Fourteen  in  New  York,  and  the  Mayor's 
Vice  Commission  of  Chicago.  These  committees  are  agreed  on  the 
need  of  stern  repression  of  overt  vice ;  of  a  more  wide-spread  dissemina- 
tion of  medical  knowledge  among  lay  adults;  of  sound,  thorough 
education  of  the  young  in  the  fundaments  of  sex  hygiene;  of  strict 
enforcement  of  individual  responsibility;  and  of  the  paying  of  a 
"living  wage"  to  girls  employed  in  the  industries.  They  also  recom- 
mend the  abolition  of  the  rear  door  and  hotel  features  in  connection 
with  the  saloon.  Of  especial  significance  is  the  fact  that  the  com- 
mittees are  unanimous  in  the  belief  that  crusades,  and  the  like,  are 
harmful,  particularly  when  conducted,  as  they  often  are,  by  misguided 
fanatics. 

The  question  arises.  Are  the  regulations  suggested  by  these  com- 
mittees sufficient  to  govern  the  evil,  or  is  the  regulation  or  supervision 
of  prostitution  by  municipal  authorities  advisable?  Before  deter- 
mining so  important  a  point,  let  us  review  briefly  the  methods  in  force 
in  the  various  civiUzed  countries  to  control  this  evil. 

Germany. — Prostitution  is  recognized  as  a  necessary  evil,  and 
municipal  attempts  are  made  to  control  it.  The  method  employed 
varies  somewhat  in  the  different  cities.  In  general,  the  principle  is 
somewhat  as  follows:  A  special  pohce  department  has  been  organized 
to  control  prostitution.  These  police  officers  are  known  as  the  "Sit- 
ten-Polizei,"  and  are  divided  into  two  groups — one  to  control  the 
prostitutes,  the  other  being  the  medical  department.  The  work  of  the 
police  department  consists  in  a  general  supervision  of  the  prostitutes. 
If  a  woman  is  seen  soliciting  in  the  streets  she  is  questioned  and 
cautioned.  If,  in  spite  of  this  warning,  she  is  again  found  soliciting, 
she  is  brought  to  the  police  station,  where  she  is  again  warned,  and 
given  a  booklet  containing  information  concerning  institutions  and 
organizations  to  which  women  may  apply  for  assistance  and  medical 


PROSTITUTION  153 

aid,  and  describing  the  dangers  of  illicit  intercourse,  venereal  diseases, 
and  their  method  of  spread,  etc.  If  she  is  under  age,  notice  is  sent  to 
her  parents.  If,  despite  these  warnings,  she  persists  in  her  course  of 
life,  she  is  examined,  and  if  found  to  be  diseased,  she  is  sent  to  a  hos- 
pital, where  she  is  detained  until  the  period  of  her  infectiousness  is 
over.  If  she  is  found  to  be  free  of  disease,  she  is  inscribed,  and  given 
a  book  that  is  countersigned  at  each  medical  examination.  No  girl 
under  eighteen  j-ears  of  age  is  inscribed,  although  if  she  is  found  to  be 
infected  she  may  be  sent  to  a  hospital  for  treatment.  These  police 
wear  plain  clothes  and  perform  their  duties  unostentatiously.  If 
arrest  is  necessary,  a  closed  cab  is  employed.  The  police  records  are 
available  only  to  the  "Sitten-Polizei."  This  department  occupies 
separate  buildings  having  private  entrances,  exits,  and  waiting-rooms 
for  the  women.  The  entire  proceedings  are  conducted  with  as  little 
publicit}^  as  possible,  and  the  women  are  well  treated.  The  city  of 
Berlin  (2, .500, 000  population)  is  divided  into  twelve  districts,  each  of 
which  has  a  physician  in  charge.  All  first  examinations  are  performed 
by  a  female  physician,  who  receives  12,000  Marks  per  annum;  the 
physicians  in  charge  receive  24,000  ]Marks  each.  No  woman  can  be 
inscribed  who  can  show  that  she  is  earning  money,  however  little,  by 
means  other  than  prostitution.  The  attitude  of  the  "Sitten-PoUzei" 
is  governed,  even  to  the  minutest  details,  by  printed  rules.  These 
rules  make  it  easy  for  women  to  have  their  names  removed  from  the 
inscribed  lists  and  police  regulation  if  they  show  evidences  of  wishing 
to  reform. 

In  Dresden  the  medical  examination  is  conducted  in  a  most 
scientific  maimer.  It  consists  of  a  thorough  general  examination,  and 
the  making  of  smears  and  cultures  from  scrapings  from  the  cervix  and 
urethra.  The  prostitutes  are  divided  into  three  classes:  Class  1 
consists  of  all  women  under  twenty-four  years  of  age;  of  all  women 
who  have  not  been  under  control  for  one  year,  and  of  all  other  women 
who  are  thouglit  Ukely  to  be  a  special  source  of  infection.  The  women 
belonging  to  this  class  are  examined  twice  a  week.  Class  2  consists 
of  women  between  twenty-four  and  thirty-four  years  of  age.  These 
are  examined  once  a  week.  Class  3  consists  of  women  over  thirty- 
four  years  old.  These  are  examined  every  two  weeks.  Definite 
hygienic  regulations  are  recommended  to  all  prostitutes.  In  addition, 
there  are  certain  special  laws  that  they  must  observe.  These  forl)id 
intercourse  with  minors.  The  prostitute  is  enjoined  to  dress  decently, 
and  to  conduct  herself  with  decorum  when  in  iniblic.  She  must  not 
frcciuent  c(>rtain  parks  and  streets.  She  nmst  not  show  lierself  at  the 
windows  of  her  dwelling,  nor  must  she  reside  near  schools  or  cliiirches. 


154  GONORRHEA   IN   WOMEN 

These  are  but  a  few  of  the  many  rules  laid  down  to  her.  In  Berlin, 
Dresden,  and  Leipzig  brothels  are  not  tolerated.  In  Hamburg  this  is 
not  the  case,  and  segregation  is  inforced.  In  the  last-named  city  there 
is  a  sick  fund  to  which  all  proscribed  prostitutes  subscribe.  This  fund  is 
used  to  defray  the  expenses  of  the  women  that  require  medical  treat- 
ment .  There  is  in  Germany  a  party  known  as  the  Abolitionists.  These 
demand  a  medical  certificate  from  each  man  about  to  marry,  and  regard 
it  as  an  intolerable  invasion  of  the  personal  liberty  of  women  to  demand 
that  a  prostitute,  who  may  daily  infect  a  dozen  men,  should  be  com- 
pelled to  submit  to  systematic  medical  examination.  In  Dresden,  since 
the  regulations  first  described  have  been  in  force,  gonorrhea  has 
diminished  40  per  cent,  among  the  women  examined  (de  Forest^). 

IMenge^  states  that  gonorrhea  is  somewhat  uncommon  in  the 
registered  prostitutes,  and  that  it  is  the  clandestine  or  secret  prostitutes 
who  are  the  real  disseminators  of  the  disease.  Excellent  results  have 
also  been  obtained  in  Hamburg.  As  the  result  of  the  regulations 
good  order  is  maintained  throughout  the  city,  a  state  of  affairs  in 
striking  contrast  to  the  conditions  that  exist  in  the  Prussian  city  of 
Altona,  an  immediate  suburb  of  Hamburg,  and  separated  from  the 
latter  only  by  an  imaginary  line.  Of  the  venereal  cases  seen  in  the 
hospitals  of  Hamburg,  70  per  cent,  came  from  Altona  (Bierhoff^).  In 
this  city  no  regulation  is  in  force.  Neisser  and  Blaschko^  declare  that 
regulation  is  of  little  value.  In  Berlin,  from  10  per  cent,  to  25  per 
cent,  of  the  prostitutes  are  under  control,  and  this  is  probably  the 
proportion  in  most  of  the  large  German  cities. 

Kelly^  states  that  in  Berlin  there  are  30,000  prostitutes,  of  whom 
2016  are  under  control;  in  Vieima,  30,000,  of  whom  3063  are  under 
control;  and  in  Paris,  45,000,  of  whom  6000  are  under  control.  Bier- 
hoff*  states  that  by  the  present  system  in  1911  there  were  3024  sources 
of  infection  withdrawn  from  circulation  in  Berlin  alone.  Weidanz' 
states  that  venereal  diseases  have  steadily  decreased  since  the  inaugura- 
tion of  the  present  system. 

There  is  in  Germany  a  National  Association  for  the  prevention 
of  venereal  disease,  known  as  the  Deutsche  Gesellschaf t  zur  Bekampf- 
ung  der  Geschlechtskrankheiten  (D.  G.  B.  G.).     Tliis  is  an  active 

'  de  Forest:  New  York  State  Jour.  Med.,  October,  1908,  p.  516. 

=  Menge,  K.:   Handbuch  der  Geschlechtskrankheiten,  Vienna,  1910. 

'  Bierhofif:  New  York  Med.  Jour.,  August  17,  1907;  also  ibid.,  March  25  and  April  1, 
1911.  .       6  ,  , 

■•  Blaschko,  A. :  Syphilis  und  Prostitution  vom  Standpunkte  der  offentlichen  Gesund- 
heitspflege,  Berlin,  1893. 

*  Kelly,  H.  A.:  Med.  Press  and  Circ,  August  14,  1912,  p.  158. 

"  Bierhoff,  F.:   New  York  Med.  Jour.,  September  21,  28,  and  October  5,  1912. 

'Weidanz:  Quoted  by  Bierhoff:   hoc.  cil. 


PROSTITUTION  155 

orgamzation,  many  eminent  men  and  women  being  eni'olled  in  its 
ranks.  Thirtj'  branch  societies  are  scattered  throughout  Germany. 
The  dues  are  3  Marks.  Each  member  receives  monthly  hterature 
regarding  the  work  accomplished  by  the  Society.  This  organization 
has  done  much  in  the  way  of  spreading  education,  increasing  hospital 
accommodations  for  venereal  patients,  and  making  venereal  disease 
an  important  branch  of  study  in  the  various  medical  schools.  The 
Society  has  distributed  a  large  number  of  educational  pamphlets. 

For  further  information  regarding  the  methods  of  dealing  with 
prostitution  in  Germany  the  reader  is  referred  to  the  exhaustive 
papers  upon  this  subject  by  Bierhoff  and  de  Forest. 

Xoricay. — In  this  country  much  is  being  accomplished  in  the  way 
of  securing  efficient  prophylaxis.  Venereal  diseases  are  reportable; 
they  are  treated  at  public  expense,  and  treatment  is  made  compulsor3\ 
Physicians  must  inform  their  patients  of  the  nature  and  contagious 
character  of  their  disease.  Patients  are  rendered  liable  for  the  expense 
of  treatment  of,  as  well  as  for  damages  suffered  by,  those  whom  they 
may  infect.  The  person  from  whom  the  infection  is  derived  is  sum- 
moned to  the  sanitary  office,  and  asked  to  submit  to  an  examination. 
If  they  accept,  and  venereal  disease  is  discovered,  free  treatment  is 
furnished,  if  desired.  If,  however,  the  examination  is  refused,  the 
individual  must  bring  a  certificate  from  a  physician  stating  that  he  or 
she  is  either  free  from  disease  or  is  undergoing  treatment.     If  a  venereal 

disease  is  present,  the  patient  must  sign  the  following  form:  "Dr. 

has  told  me  that  I  am  suffering  from  fnanie  of  disease),  a  contagious 
disease.  He  has  fully  explained  to  me  the  dangers  of  the  disease  with 
regard  to  myself  and  mj^  associates  and  its  probable  duration,  and  has 
made  clear  to  me  that  I  must  remain  under  treatment  until  he  gives  me 
a  certificate  to  bring  to  this  office  that  I  am  well  and  no  longer  a  source 
of  contagion.  I  know  that  if  I  have  sexual  intercourse  during  this 
time,  whether  I  transmit  the  disease  or  not,  I  am  liable  to  be  punished, 
under  Section  XX  of  the  laws  of  Norway."  If,  after  signing  such  a 
form,  the  patient  indulges  in  intercourse  before  he  or  she  is  pronoimced 
free  from  contagion  Ijy  the  attending  physician,  the  law  is  invoked. 
A  monetary  iiidcnmitj'  maj'  legally  be  claimed  l)y  any  man  or  woman 
who  has  knowingly  been  exposed  to  venereal  disease,  whetlier  or  not 
they  have  been  infected.  Those  in  chai'ge  of  tlic  sanitary  offices  are 
physicians. 

Sivcden  and  Finland. — These  countries  have  adopted  systems  mod- 
eled somewhat  after  that  of  Norway.  In  Sweden  segregation  is  in 
force.     Christiania  and  Copenhagen  have  abandoned  police  regulation. 


156  GONORRHEA    IN    WOMEN 

In  Stockholm  regulation  is  in  force,  but  of  the  3000  or  4000  prostitutes 
said  to  be  in  the  city,  not  more  than  500  are  under  control. 

In  1903  the  Swedish  government  appointed  a  committee  to  study 
and  report  on  the  question  of  prostitution.  After  seven  years  it  de- 
clared itself  against  reglementation.^  This  committee  stated  that — 
"The  objections  which  are  brought  to  bear  against  regulation  from  a 
social,  moral,  and  legal  standpoint  are  so  formidable  that  the  useful- 
ness which,  from  a  sanitary  point  of  view,  it  might  possess,  is  not  al- 
lowable as  a  consideration  for  its  retention." 

Holland  and  Denmark  have  abandoned  police  regulation.  In  the 
latter  country  compulsory  notification  by  number  of  venereal  diseases 
is  in  force.  There  are  also  numerous  institutions  in  which  free  treat- 
ment may  be  obtained. 

England. — In  London,  after  a  desultory  attempt  at  police  regula- 
tion, the  effort  was  abandoned.  At  present  no  attempt  is  made  at 
police  regulation.  The  transmission  of  venereal  disease  by  illicit  inter- 
course is  not  an  actionable  offense,  provided  the  congress  has  been 
voluntary,  even  though  it  can  be  shown  that  there  was  intentional  and 
wilful  concealment  of  the  disease;  nor  is  there  any  legal  offense  if  the 
husband  infects  his  wife  or  the  wife  her  husband. 

France. — In  France  prostitutes  are  under  control.  The  system 
represents  a  combined  effort  on  the  part  of  the  administration  and  the 
medical  authorities  to  render  the  practice  of  prostitution  less  dangerous 
to  the  public  health.  A  special  corps  of  police  is  employed.  Any 
woman  in  the  streets  suspected  of  prostitution  may  be  arrested.  If 
it  can  be  proved  that  she  is  a  prostitute,  her  name  is  inscribed  in  a 
special  register,  and  she  is  given  a  card,  which  is  countersigned  at  each 
medical  examination.  Inmates  of  brothels  are  examined  weekly,  and 
others  are  obliged  to  report  for  examinatioii  every  two  weeks.  When 
found  to  be  diseased,  the  prostitute  is  sent  to  a  special  hospital,  St. 
Lazar,  where  she  is  detained  until  the  infectious  stage  of  her  disease 
has  passed.  It  has  been  estimated  that  there  are  over  100,000  prosti- 
tutes in  Paris.  The  system  has  been  in  operation  for  over  fifty  years, 
and  has  been  fairly  efficient,  as  is  proved  by  Fournier's  statistics,  which 
show  that  only  7.08  per  cent,  of  infected  men  received  their  contamina- 
tion from  public  prostitutes. 

Italy. — This  country  provides  numerous  free  beds  for  her  venereal 
patients. 

Japan. — In  Japan  prostitutes  are  strictly  segregated.  The  persons 
who  conduct  the  brothels  employ  physicians  to  make  weekly  physical 
examinations   of   the  inmates.     These   examinations   are   thorough, 

'  Mitt,  d,  Deutsch.  Gesellseh.  z.  Bekampf.  d.  Geschlechtsk.,  April,  1911. 


I 


PROSTITUTION  157 

scientific,  and  modern.  These  persons  also  contribute  toward  the 
maintenance  of  the  hospitals  where  contaminated  prostitutes  are  con- 
fined and  treated  during  the  period  of  their  infectiousness.  The  Jap- 
anese sj'stem  is  maintained  not  so  much  by  law  as  by  public  sentiment. 

Austro-Himgary. — In  Budapest  from  1700  to  2000  prostitutes  are 
under  control.  These  constitute  about  40  per  cent,  to  50  per  cent,  of 
the  total  number.  This  control  is  exercised  over  prostitutes  from  all 
classes,  differing  radically  in  this  respect  from  the  German  cities  and 
from  Paris,  where  the  inscribed  prostitutes  are  chiefly  of  the  lower 
class.  In  Budapest  registration  is  voluntarj^  but  constitutes  the  only 
means  by  which  a  prostitute  can  avoid  arrest  and  punishment.  The 
control  is  associated  with  medical  examination,  which,  however,  is 
less  thorough  than  in  Germany. 

According  to  Guiteras,^  registration  of  prostitutes  is  in  force  in 
Havana. 

United  States. — In  this  country  the  method  of  dealing  with  the  evil 
of  prostitution  varies  quite  markedly  in  different  localities,  owing  to 
the  State  laws.  In  general,  the  feeling  is  strongly  against  any  form 
of  official  recognition.  Supervision  has  been  attempted  in  a  few 
cities,  but  has  never  met  with  the  success  hoped  for  by  its  advo- 
cates. In  Detroit  regulation  was  in  force  for  one  year  and  was  then 
abandoned.  At  that  time  Detroit  had  a  population  of  400,000.  It 
contained  about  125  houses  of  ill  fame,  having  500  registered  in- 
mates. The  great  prevalence  of  venereal  diseases  in  New  York  has 
recently  forced  the  authorities  to  take  some  action  to  remedy  the  evil. 
As  a  result,  the  Page  Bill,  Paragraph  79,  in  1910  become  a  law.  This 
law  provided  for  "the  medical  examination,  by  a  woman  physician  of 
the  Board  of  Health,  of  all  females  convicted  of  prostituting  or  solicit- 
ing, and  the  commitment  of  persons  of  this  class  who  may  be  found 
affected  with  any  venereal  disease  which  is  contagious,  infectious,  or 
communicable,  to  public  hospitals,  having  a  ward  or  wards  for  the 
treatment  of  the  disease  with  which  she  is  afltlicted,  for  detention  and 
treatment  for  a  minimum  period  fixed  by  him  in  the  commitment  and 
for  a  maximum  period  for  which  she  is  committed  to  such  an  institu- 
tion. She  shall  be  discharged  and  released  from  custody  upon  the 
written  order  of  the  officer  in  charge  of  the  institution  to  which  she  is 
committed,  upon  the  certificate  of  a  physician  of  such  institution  or  of 
the  department  of  health  that  the  prisoner  is  free  of  any  venereal  dis- 
ease which  is  contagious,  infectious,  or  communicable.  If,  however, 
such  prisoner  shall  be  cured  prior  to  the  expiration  of  such  minimum 
period  for  which  she  was  committed,  she  shall  be  transferred  to  the 

>  Guitcras,  R.:  Amer.  Jour.  Pub.  Ileallh,  .March,  1912,  p.  204. 


158  GONORRHEA    IN   WOMEN 

workhouse  and  discharged  at  the  expiration  of  such  minimum  period" 
(Bierhoff).  No  certificate  of  any  kind  is  given  to  the  woman.  Ac- 
cording to  the  Board  of  PoUce  Magistrates,  the  law  was  effecting  some 
good.  After  having  been  in  force  about  a  year,  the  Page  law  was 
declared  unconstitutional.  As  a  result,  examinations  were  suspended 
in  June,  1911.  Schenck^  states  that  regulation  is  in  force  in  San 
Francisco  and  in  Norfolk.  He  beUeves  that  the  system  has  been 
satisfactory  in  the  latter  city.  In  Salt  Lake  City  prostitution  is 
ignored  (1909),  but  the  officials  exact  a  Ucense  under  the  name  of  a 
bond.  There  are  laws  against  prostitution,  but  these  are  not  inforced. 
Segregation  is  practised  to  a  certain  extent.  The  modus  operandi  of 
the  bond  is  as  follows :  Every  month  the  prostitutes  are  arrested  and 
are  then  bonded  for  $10.00  or  $15.00  a  head  to  appear  and  answer  the 
charge  of  vagrancy.  As  they  never  appear,  the  bond  is  forfeited,  and 
the  money  goes  into  the  city  treasury,  and  is  equivalent  to  a  Ucense 
fee.  A  somewhat  similar  custom  is — or  at  one  time  was — in  force  in 
New  Orleans.  In  the  majority  of  cities  of  the  United  States  prostitu- 
tion is  not  officially  recognized  and  is  considered  an  offense.  Unless, 
however,  it  becomes  too  flagrant,  no  efforts  are  usually  made  to  suppress 
the  traffic.  The  fact  that  it  is  illegal  opens  an  avenue  for  "graft" 
by  petty  police  officers  that  practically  amounts  to  a  license  system. 
Instead,  however,  of  swelling  the  city  treasury,  the  money  remains  in 
the  hands  of  the  police  and  ward  politicians.  Owing  to  the  prevalence 
of  venereal  disease  in  the  Philippines,  it  has  been  found  necessary,  in 
some  localities,, to  issue  a  certificate  of  health  to  the  women  practising 
prostitution.  The  question  as  to  the  advisability  of  securing  official 
recognition  of  prostitution  in  the  United  States  is  an  extremely  grave 
one,  and  a  decision  should  not  be  reached  before  a  careful  considera- 
tion of  all  the  facts  bearing  on  the  case  is  made.  Much  has  been  writ- 
ten on  this  subject,  both  in  Europe  and  in  this  country.  Many  of  those 
antagonistic  to  the  official  recognition  of  prostitution  are  influenced 
largely  by  the  moral  aspects  of  the  question.  The  following  is  a  con- 
densed summary  of  the  arguments  that  have  been  advanced  for  this 
official  recognition : 

ARGUMENTS  FOR  AND  AGAINST  THE  OFFICIAL  REGULATION  OF 
PROSTITUTION 

1.  Prostitution    is   immoral    and    should,         L  This  is  undoubtedly  a  strong  argument. 

therefore,  not  be  licensed.  Many  authorities  believe  that  regula- 

tion is  the  lesser  of  the  two  evils. 

2.  Regulation  does  not  regulate,  and  segre-  2.  Efficient  regulation  is  a  matter  of  money 
gation  does  not  segregate.  Regulation  and  can  be  obtained  by  paying  for  it. 
has  been  in  force  for  fifty  years  in  Paris  Note  the  excellent  results  obtained  in 
and  venereal  disease  is  still  prevalent.  Germany.     If  regulation  had  not  been 

'  Schenck,  P.  S.:  Jour.  Amer.  Med.  Assoc,  November  23,  1912,  p.  1916. 


PROSTITUTION 


159 


Arguments  For  and  Agaixst  the  Official  Regulation  of  PROSTmrrioN — (Continued) 
Regulation    has    been    abandoned    in  believed  to  be  of  ser\-ice,  it  would  not 

many  countries.     This  would  not   be  have  been  maintained  for  fifty  years 

the  case  if  it  had  given  satisfactory  in  Paris, 

results. 


3.  Regulation    would    tend    to    augment 
poUce  "graft." 


4.  One  of  the  greatest  protections  against 
illicit  intercourse  is  the  fear  of  con- 
tracting venereal  disease.  By  regula- 
tion and  medical  examination  this 
would,  to  a  great  extent,  be  done  away 
with,  and,  therefore,  tend  to  increase 
immorality. 

5.  Medical  examination  is  inefficient.  In 
many  cases  venereal  disease  can  be 
diagnosed  only  by  the  specialist,  and 
with  the  greatest  difficult}'. 


6.  It  is  impossible  to  control  all  women 
practising  prostitution;  even  in  cities 
where  regulation  is  most  favorably 
carried  out  only  a  small  proportion 
of  the  prostitutes  are  under  control. 


At  best,  regulation  affects  only  the 
women,  while  the  men  are  quite  as 
virulent  spreaders  of  venereal  disease. 


8.  It  is  impracticable  to  hou.sc  all  the  in- 
fected prostitutes  in  public  institutions. 


9.  Segregation  produces  centers  of  crime 
and  depreciates  the  value  of  property. 


10.  Segregation  lends  to  increase  the  pub- 
licity of  prostitution. 

II    Faults   of   administration   often   cause 
failure  in  the  licensing  system. 


3.  As  prostitution  is  now  illegal,  "graft" 

at  present  is  prevalent.  The  city 
authorities  recognize  that  prostitution 
is  necessary,  and  therefore  do  not  inter- 
fere, but  allow  the  prostitute  to  pay 
the  poHce  of  her  district  for  protection. 

4.  This  argument  cannot  be  entirely  re- 
futed. Certain  extremists,  however, 
claim  that  on  this  basis  our  attitude 
should  be  to  favor  the  spread  of  venereal 
disease,  so  as  in  this  way  to  make  illicit 
intercourse  more  dangerous. 

5.  With  the  aid  of  the  Wassermann  reac- 

tion and  modern  methods  of  cultures 
and  staining  of  the  gonococcus,  diag- 
nosis is  not  difficult — certainly  not  so 
in  cases  likely  to  produce  infection. 

6.  Regulation  is  not  a  means  of  eradicating 
venereal  disea.se,  Init  for  every  infected 
prostitute  that  is  controlled,  a  certain 
number  of  cases  of  venereal  disease  are 
prevented.  The  lower  class  of  prosti- 
tutes are  the  ones  that  always  come 
under  control,  and  are  those  in  whom 
regulation  is  most  necessary. 

7.  Whereas  a  man  has  intercourse  v.ith 
one  woman,  a  prostitute  has  inter- 
course with  twenty  or  more  men.  But 
a  small  proportion  of  infected  men  will 
practise  fornication,  as  they  all  know 
that  the}'  are  infected.  Some  women 
are  not  aware  of  their  condition, 
whereas  others  will  continue  their  trade 
for  financial  reasons. 

8.  The  large  number  shows  the  urgency  of 
reducing  the  amount  of  venereal  disease. 
Only  tho.se  in  an  infectious  state  need 
be  incarcerated.  It  would  seem  that 
the  new  Ehrlich-IIatta  specific  may 
greatly  diminish  the  time  required  to 
effect  the  cure  of  syphilis.  Gonorrhea 
is  a  curable  disease. 

9.  Segregation  tends  to  prevent  the  dis- 
semination of  vice,  aiifl  therefore  pro- 
tects the  innocent.  Districts  should 
be  well  lighted.  Segregation  is  a 
natural  result.  Every  large  city  has 
its  "tenderloin,"  where  property  is  not, 
as  a  rule,  cheap. 


10. 


This  is  not  the  case,  as  witness  Hamburg 
and  other  cities. 


11.  Becau.se  a  system  is  inotlicieiilly  ad- 
ministered, it  does  not  follow  that  it  is 
without  value. 


150  GONORRHEA   IN   WOMEN 

Arguments  For  and  Against  the  Official  Regulation  op  Prostitution — (Continued) 

12.  Regulation  would  increase  the  number       12.  Not   the    case.     But   rather   tends   to 

of  prostitutes.  lessen    the    dangers    of    seduction    of 

innocent  girls. 

13    Medical  examination  of  prostitutes  is       13.  It  is  difficult  to  understand  what  injury 
an  outrage  upon  the  sex  and  tends  to  a  medical  examination  can  do  to  the 

degrade  the  woman.  modesty  of  a  class  whose  trade  necessi- 

tates the  abandonment  of  all  modesty 
and  the  habitual  exposure  of  the  person 
for  hire.  Moreover,  professional  ex- 
aminations for  the  detection  of  disease 
are  common  occurrences  of  every-day 
life,  and  are  not  held  to  be  in  the  nature 
of  an  assault,  even  when  made  against 
the  will  of  the  individual,  as  in  quaran- 
tine inspections  or  examination  of  sol- 
diers held  in  our  own  and  most  other 
armies,  for  the  purpose  of  detecting 
venereal  and  other  diseases  (J.  R. 
Kean'). 

The  foregoing  summary  appears  to  favor  official  recognition  of 
prostitutes.  The  crux  of  the  situation  is  not  whether  such  recognition 
could  do  good  by  lessening  venereal  diseases,  but  whether  such  a 
system  could  be  efficiently  enforced  in  the  face  of  so  many  difficulties. 
It  is  the  author's  belief  that,  in  this  country  at  least,  it  could  not 
be  enforced  for  reasons  that  will  be  stated  further  on. 

Harwood^  tells  of  regulation  in  a  settlement  of  steel  workers  the 
force  of  which  was  crippled  by  venereal  disease.  Medical  examination 
and  cooperation  with  the  keepers  of  the  brothels  produced  good  results. 
Many  similar  instances  are  recorded  in  military  posts  and  garrisons. 
It  has  been  suggested  that  brothels  be  licensed  by  the  municipal  au- 
thorities, somewhat  in  the  same  manner  that  saloons  are  at  present 
licensed  in  this  country,  the  license  to  be  a  liigh  one.  It  is  claimed  that 
this  system  would  in  some  measure  do  away  with  many  of  the  present 
objectionable  features  of  prostitution.  The  poUce  would  know  the 
location  of  each  brothel,  and  could  easily  locate  an  inmate  whenever 
desired.  If  desired,  segregation  could  readily  be  enforced.  Petty 
robberies  and  disorder  would  diminish  or  disappear,  for  a  proprietor 
would  not  risk  losing  a  license  for  which  a  large  sum  was  paid  annually — 
say  $1000 — for  insignificant  gains.  There  would  be  fewer  houses 
of  ill  repute,  and  those  that  did  exist  would  be  better  kept.  The 
present  "graft"  of  the  police  would  be  done  away  with.  The  sys- 
tem would  soon  pay  for  itself.  The  "white  slave"  traffic  and  the 
harboring  of  minors  would  be  lessened,  if  not  entirely  eliminated. 
The  cancellation  of  the  license,  if  the  regulations  were  not  obeyed, 
would  always  be  a  weapon  to  hold  over  the  head  of  the  proprietor. 

'  Kean,  J.  R.:  Mihtary  Surgeon,  March,  1912,  p.  251. 
'  Harwood:  Jour.  Amer.  Med.  Assoc,  December  22,  1906. 


PROSTITUTION  161 

The  fact  that  the  houses  were  well  managed  would  tend  to  drive  the 
clandestine  prostitute  and  dive-keeper  out  of  business,  and,  lastly, — a 
very  important  point, — the  sale  of  liquor  in  brothels  could  be  sup- 
pressed entirely.  The  trade  with  minors — and  there  is  no  doubt  that  at 
present  minors  constitute  a  very  definite  proportion  of  the  frequenters 
of  certain  houses  of  ill  repute — would  be  eliminated.  The  system 
might  easily  be  co'mbined  with  medical  supervision,  but  this  would 
seem  to  be  superfluous,  since  it  would  be  to  the  proprietor's  advantage 
to  harbor  only  such  inmates  as  are  free  from  disease.  A  complete 
set  of  regulations  would  have  to  be  drawn  up,  and  it  would  be  made 
compulsory  for  the  keepers  of  such  licensed  bi'othels  to  observe  them 
and  see  that  they  are  enforced.  It  would  be  necessary  to  combine  with 
the  foregoing  sj'stem  a  vigorous  police  crusade  against  all  unlicensed 
brothels  and  street  prostitutes.  This  plan  requires  the  legalization  of 
prostitution.  Prostitution  is  now  illegal,  and  therefore  the  police  can- 
not be  asked  to  supervise  it.  Xo  law  can  be  efficiently  enforced  unless 
it  is  satisfactory  to  the  majoritj'  of  the  people.  It  seems  almost 
certain  that  the  American  people  would  not  tolerate  the  legalization 
of  prostitution. 

.Vt  the  present  day  the  inmates  of  many  of  the  more  luxurious 
brothels  are  examined  at  regular  intervals  by  a  physician  employed  by 
those  in  charge  of  the  establishments.  In  Russia,  in  some  of  the  houses 
of  ill  fame,  a  student  physician  is  retained,  who  not  only  treats  the 
inmates,  but  examines  all  the  male  patrons. 

Excluding  the  moral  aspect,  theoretically  regulation  of  prostitution 
should  tend  greatly  to  lessen  the  prevalence  of  venereal  disease,  and 
has  been  proved  to  do  so  in  many  of  the  smaller  communities.  With 
the  possil)le  exception  of  Germany,  practical  experience  has  thus  far 
failed  to  demonstrate  the  advantages  claimed  for  regulation.  Powell^ 
states  that  in  St.  Louis  regulation  did  not  lessen  disease,  but  did  in- 
crease licentiousness.  Nevins'  states  that  the  system  of  regulation 
iioininally  established  in  India  in  1888  was  a  failure. 

The  strife,  as  it  at  present  exists,  between  the  abolitionist  and  the 
regulationist,  is  a  fruitless  battle.  The  animosity,  if  not  intolerance, 
that  is  often  exhibited  by  the  former,  and  that  almost  wrecked  the 
Brus.sels  Congress  of  1906,  is  well  known.  Arguments  as  to  the  ad- 
visability of  devising  some  means  for  lessening  venereal  disease  may 
easily  demonstrate  conclusions  upon  the  one  side,  but  sentiment  and 
convent ionality  are  equally  powerful  in  fornuilating  contrary  con- 
clusions. 

'  Powell:  Quoted  by  .J.  M.  Mabbott,  Trans.  \ew  York  Olwt.  Soe .,  liMm-l'.tll,  p.  .iss. 
'  Nevins:  Quoted  by  J.  M.  Mablsott,  loc.  cil. 
11 


162  GONORRHEA    IN    WOMEN 

Great  diversity  of  opinion  exists  as  to  the  benefits  to  be  derived 
from  tlie  attempted  reformation  of  prostitutes.  Certainly  tfie  atti- 
tude that  is  exhibited  by  the  Cierman  government  toward  these  women 
deserves  praise.  Even  hardened  prostitutes  can  scarcely  be  regarded 
as  criminals,  and  there  can  be  no  two  opinions  as  to  the  younger  mem- 
bers of  this  profession.  It  is  nevertheless  a  sad  fact,  admitted  by 
most  authorities  on  this  subject,  that  attempts  at  rescue  of  prostitutes 
are  not  attended  by  marked  success.  There  are  in  Greater  New 
York  24  reformation  and  rescue  homes.  The  work  done  by  these 
institutions  is  most  praiseworthy,  but  the  percentage  of  permanent 
reformations  that  are  effected  is  comparatively  small.  Unless  the 
prostitutes  are  young  or  are  reached  early  in  their  career,  success 
rarely  follows  such  efforts. 

After  an  exhaustive  study  of  the  subject  of  prostitution  and  a  care- 
ful review  of  the  literature,  the  author  is  led  to  the  following  conclu- 
sions: (1)  That  efficient  regulation  of  prostitution  is  possible,  and  would 
undoubtedly  lessen  the  spread  of  venereal  disease.  Unfortunately, 
practical  experience  has  shown  that  regulation  in  large  cities  is  attended 
by  so  many  almost  insurmountable  difficulties  that  its  beneficent 
efTects  are  almost  nugified.  Theoretically,  regulation  should  be 
possible  and  eflScient,  but  results  do  not  sustain  the  theory.  Excel- 
lent results  have  followed  regulation  in  small  communities,  such  as 
military  posts,  etc.,  but  in  large  cities  it  is  nearly  impossible  to  enforce 
regulation  with  suflficient  stringency  to  be  of  any  service.  (2) 
Owing  to  the  high  cost  of  living  and  low  wages  there  is,  in  this  coun- 
try, an  ever-increasing  class  of  young  women,  drawn  largely  from 
the  shop-girls  and  others  who  are  forced  to  earn  their  own  living,  that 
are  immoral.  These  girls  are  not  prostitutes,  in  the  ordinary  sense  of 
the  word,  and  are  not  so  considered  by  their  associates.  They  are 
generally  included  in  the  class  termed  clandestine  prostitutes,  and  are 
for  the  most  part  girls  who  are  forced  to  add  to  their  incomes  in  some 
way.  The  Chicago  Vice  Commission,  in  its  recent  report,  has  amply 
proved  this  point.  Peterkin'  states  that  in  Seattle  the  clandestine  out- 
number pubhc  prostitutes  10  to  1.  Kelly-  believes  that  all  vice  is 
a  reflex  of  social  conditions — of  poor  housing  and  poor  wages.  He 
finds  that  in  Baltimore  80  per  cent,  of  the  women  employees  in  depart- 
ment stores  receive  less  than  a  living  wage.  Regulation  cannot  reach 
this  class.  Nevertheless,  while  it  is  impossible  ever  to  regulate  all 
prostitutes,  this  should  not  detract  from  the  good  that  can  be  accom- 
plished by  the  control  of  some  of  them.     (3)  It  would  be  unwise  to 

'  Peterkin,  G.  S.:  Amer.  Jour.  Dermat,,  August,  1912,  p.  407. 

2  Kelly,  H.  A.:  Jour.  Amer.  Med.  Assoc,  October  5,  1912,  p.  1312. 


PROSTITUTION  163 

attempt  official  regulation  of  prostitution  in  this  country,  owing  chiefly 
to  the  strong  public  sentiment  that  exists  against  such  a  procedure. 
(4)  At  best,  regulation  of  prostitution  is  of  comparatively  minor  im- 
portance in  the  cjuestion  of  the  prophylaxis  of  venereal  disease,  com- 
pared with  educational  and  other  methods,  some  of  which  will  be  de- 
scribed in  the  following  chapter.  These  offer  a  far  better  prospect  for 
the  ultimate  solution  of  this  difficult  problem. 

REFERENCES 

1.  Bicrhotf :  New  York  Med.  Jour.,  August  17,  1907,  pp.  24  and  31. 

2.  HierhofF:  New  York  Med.  Jour.,  March  2.5  and  April  1,  1911. 

3.  de  Fore-st:  N.  Y.  State  Jour.  Med.,  October,  1908,  p.  516. 

4.  Demeritt:   .\nier.  Jour.  Dprraat.  and  Gen.-Urin.  Diseases,  1910,  vol.  xiv,  p.  422. 

5.  Ellis:   Med.  Record,  July  11,  1908. 

6.  Greene:  Cal.  State  Jour.  Med.,  January,  1910,  p.  15. 

7.  Harwood:  Jour.  Amer.  Med.  Assoc,  December  22,  1906. 

8.  Hund:  Amer.  Jour.  Dermat.  and  Gen.-Urin.  Diseases,  1909,  vol.  ,\iii,  p.  23. 

9.  Kime,  R.  R.:  Atlantic  Jour.-Record  of  Med.,  April,  1911. 

10.  Lecky:   History  of  European  Morals. 

11.  Newcomb:   Cleveland  Med.  Jour.,  February,  1911,  p.  98. 

12.  Social  Evil  in  Chicago,  Report  of  the  Vice  Commission,  1911. 

13.  Tuffier:   Jour.  Amer.  Med.  Assoc,  October  20,  1906. 

14.  Vecki:   .\mer.  Jour.  Dermat.  and  (!en.-Urin.  Diseases,  1910,  vol.  xiv,  p.  213. 
lo.  WestmirLster  Review,  December,  1899,  p.  608. 

16.  Williams:  Lancet,  1906,  vol.  i,  p.  361. 

17.  Report  of  the  Committee  of  Seven,  Med.  Record,  December  21,  1901. 

15.  Keifer  and  Kober:    Report  of  Committee  on  Control  of  Venereal  Disease  by  a  Mu- 
nicipality, Jour.  Amer.  Med.  Assoc,  September  23,  1911. 

Chiefly  .\merican  and  English  literature  has  purposely  been  referred  to  in  the  considera- 
tion of  this  subject. 


CHAPTER  VII 

PROPHYLAXIS— METHOD  OF  DEALING  WITH  GONORRHEICS  TO 
PREVENT  THE  SPREAD  OF  THE  DISEASE 

One  of  the  most  important  points  in  securing  efficient  prophylaxis 
against  venereal  disease  lies  in  effecting  sterilization  of  the  source  of 
infection.  The  regulation  of  prostitution,  even  if  properly  enforced, 
controls  only  the  female  gonorrheic,  the  male  being  free  to  spread  the 
disease,  and  although  the  woman  is  for  many  reasons  the  most  prolific 
source  of  infection,  the  man  is  an  undoubted  factor,  and  must  be  taken 
into  consideration  if  any  satisfactory  campaign  against  ^'enereal  dis- 
ease is  to  be  instituted.  The  necessity,  therefore,  of  completely  curing 
all  venereal  patients  cannot  be  overestimated.  A  large  j^roj^ortion  of 
venereal  patients  are  unable  to  afford  the  services  of  a  private  physi- 
cian, and  the  dispensary,  and  especially  the  hospital  ward,  acconuno- 
dations  open  to  such  patients  in  this  country  are  entirely  inadequate. 
In  New  York  city,  in  1910,  of  49  general  hospitals,  only  11  admitted 
venereal  patients.  Of  10,536  hospital  beds,  400  were  open  to  venereal 
patients,  and  these  were  not  reserved  for  them  exclusively,  but  were 
used  for  genito-urinary  patients  in  general.  Of  these  49  hospitals,  36 
were  municipal  institutions  (Bierhoff^).  In  1908,  in  Boston,  only  one 
hospital  would  receive  a  case  of  syphihs.  In  Philadelphia  the  Phila- 
delphia General  Hospital  is  the  only  institution  that  freely  admits 
venereal  patients.  Christian-  states  that  he  sent  a  communication  to 
14  hospitals  in  Pennsylvania,  all  but  one  of  which  received  State  aid, 
requesting  information  as  to  whether  or  not  they  admitted  ^•enereal 
patients.     A  negative  answer  was  received  in  every  case. 

In  Cook  County,  111.,  there  is  only  one  hospital  where  venereal 
patients  can  receive  free  treatment,  and  there  is  only  one  other  hospi- 
tal in  Chicago  where  pay  venereal  disease  patients  will  be  received.' 
A  similar  state  of  affairs  exists  all  over  our  country.  Increased  hos- 
pital facilities  for  venereal  patients  constitute  a  crying  need. 

The  Commission  of  the  Medical  Society  of  Pennsylvania''  has  re- 

'  Bicrhoff:  New  York  Med.  Jour.,  August  17,  1907;  also  ibid.,  March  25  and  April  1, 
1911. 

2  Christian,  H.  M.:  The  Pennsylvania  Med.  Jour.,  July,  1912,  p.  790. 
'  The  Social  Evil  in  Chicago,  1911,  p.  304. 

*  Report  of  the  Med.  Soc.  of  Pa.,  sixty-first  annual  meeting,  September  25-28,  1911. 
164 


PROPHYLAXIS  165 

cently  recommended  that  a  medical  certificate  certifying  that  the 
applicant  is  free  from  venereal  or  other  contagious  diseases  be  de- 
manded from  every  man  who  contemplates  marriage;  that  one  who 
conveys  venereal  disease  should  be  punished  by  imprisonment,  and 
that  provision  should  be  made  for  securing  segregation,  so  that  the 
pubUc  maj^  be  protected.  These  recommendations  were  accepted  by  the 
Society.  The  following  resolution  has  recently  been  passed  by  the 
New  York  Obstetrical  Society^:  "That  the  time  has  come  to  make  a 
beginning  in  the  regulation  and  control  of  venereal  diseases.  That  the 
first  necessity  is  a  place  of  detention  and  care  for  flagrant  and  especially 
dangerous  cases."  Fournier,  Neisser,  Brieux,  and  all  authorities  on 
this  subject  strongly  recommend  increased  hospital  facilities  for  ven- 
ereal patients  as  a  means  of  prophylaxis.  Fournier  suggests  that  not 
only  should  dispensaries  be  increased  in  number,  and  that  each  should 
have  a  number  of  small  consulting-rooms,  but  that  they  should  be 
open  for  two  hours  in  the  day  and  for  a  similar  period  in  the  evening. 
This  last  is  an  important  suggestion,  more  especially  for  men,  who  in 
many  cases  cannot  leave  their  work  during  the  day  for  treatment. 

Bernart-  found  that  of  a  series  of  50  male  venereal  patients,  only 
25  were  able  to  leave  their  work  for  treatment  during  the  day.  The 
genito-urinary  dispensary  should  be  designated  by  a  letter  or  number, 
so  as  to  avoid  the  objectionable  term,  diseases  of  men.  A  female 
physician  is  of  great  assistance  in  a  gynecologic  dispensary,  for  a  cer- 
tain proportion  of  women  prefer  her  to  a  male  practitioner.  The 
treatment  in  dispensaries  for  both  men  and  women  should  be  modern, 
and  combined  with  facilities  for  making  exact  laboratory  methods  of 
diagnosis.  Each  patient  should  be  warned  of  the  nature  and  con- 
tagiousness of  his  or  her  disease.  In  the  Teleia  dispensaries  in  Buda- 
pest the  patient,  if  married,  is  warned  of  the  infectiousness  of  the  dis- 
ease, although  care  is  taken  not  to  incriminate  the  husband  or  wife,  as 
the  case  may  be.  The  possibility  of  extragenital  infection  is  dwelt 
upon,  and  an  effort  is  made  to  have  the  partner  in  marriage  come  to  the 
dispensary  for  examination  and  treatment.  Unmarried  patients  are 
told  of  the  chronic  and  sometimes  latent  character  of  their  disease,  and 
are  advised,  in  case  of  intended  marriage,  to  return  for  a  further 
examination.  The  Teleia  dispensaries  are  successful  along  these  lines, 
and  the  patients  usually  act  on  the  suggestions  made. 

.\n  excellent  plan  is  that  suggested  by  Rathburn,''  who  gives  each 
venereal  |):itient  a  small  pamphlet.     He  finds  that    patients  nearly 

'  Trans.  New  York  Obst.  Soc,  1<«)>»-1<.)10. 

'  Bernart:  Amer.  Jour.  Derniat.,  1908,  p.  270. 

'  Rathburn:  Long  Island  Med.  .Jour.,  19()K,  p.  24. 


166  GONORRHEA    IN    'WOMEN 

always  take  these  home  and  read  them.  These  pamphlets  explain  the 
nature  and  infectious  character  of  their  disease,  its  contagiousness,  and 
dwell  upon  the  necessity  of  continuing  the  treatment  until  a  cure  is 
effected.  Such  pamphlets  can  be  printed  at  a  very  small  cost.  Rath- 
burn  has  separate  ones  for  the  use  of  gonorrheics  and  syphihtics. 
Those  intended  for  patients  suffering  from  gonorrhea  read  as  follows: 

Rathburn's  Pamphlet 

"Gonorrhea,  or  clap,  as  it  is  generally  called  by  the  laity,  is  a  disease 
that  is  caused  by  a  special  germ  or  microorganism;  whenever  these 
germs  are  deposited  upon  a  mucous  membrane,  as,  for  example,  the 
genital  organs,  gonorrhea  results.  The  disease  is  usually  transmitted 
from  one  to  another  by  means  of  sexual  intercourse.  It  is  possible  to 
contract  the  infection  through  contamination  from  water-closets  and 
other  sources,  if  these  have  previously  been  infected  by  some  one 
having  the  disease. 

"It  usually  manifests  itself  in  from  three  to  ten  days  after  exposure. 
The  first  symptom  is  a  stinging  pain  on  urination,  followed  by  the  dis- 
charge of  pus  from  the  urinary  canal.  Each  drop  of  this  pus  contains 
millions  of  bacteria  and  is  highly  contagious.  Its  virulence  may  be 
estimated  from  the  fact  that  a  small  drop,  placed  in  the  eye,  would 
completely  destroy  this  organ  in  one  or  two  days. 

"The  disease,  if  properly  treated,  may  be  entirely  cured  in  from  four 
to  six  weeks.  So-called  '  cures '  that  claim  to  take  effect  in  a  shorter 
time  are  frauds.  When  neglected  or  improperly  treated,  the  disease 
becomes  one  of  the  most  dreadful  conditions  that  affect  mankind,  and  one 
of  the  most  difficult  to  cure.  It  occasionally  results  in  complete  loss  of 
sexual  power,  and  sometimes,  when  neglected  too  long,  becomes  abso- 
lutely incurable. 

"Men  often  believe  themselves  cured  because  there  is  no  running  or 
discharge,  but  a  close  examination  on  arising  in  the  morning  will  often 
disclose  the  presence  of  a  small  drop,  or  if  this  is  absent,  the  urine,  when 
passed  into  a  small  glass,  will  show  a  cloudiness  or  a  number  of  small 
shreds  or  particles  (normally,  urine,  when  passed,  should  be  clear). 
These  particles  often  contain  large  numbers  of  germs.  At  this  stage  the 
disease  is  just  as  contagious  as  when  an  abundant  discharge  is  present.  It 
is  by  this  class  of  cases,  occurring  among  men  who  think  they  are  cured, 
but  who  in  reality  are  not,  that  the  disease  is  spread  abroad,  or  the  newly 
married  man  may  infect  his  wife.  The  latter  may  have  but  little  or 
no  trouble  at  the  time,  but  later  on  she  becomes  a  chronic  invalid, 
securing  relief  only  as  the  result  of  a  severe  surgical  operation,  occasion- 
ally involving  the  removal  of  the  entire  uterus.     Nearlv  one-third  of 


PROPHYLAXIS  167 

all  the  grave  operations  performed  upon  women  in  hospitals  are  done 
for  diseases  that  had  their  origin  in  this  cause.  If  children  result  from 
the  marriage,  there  is  a  possibility  of  their  being  blind  from  birth. 
Practically  all  children  blind  from  birth — and  there  are  thousands  of 
such  cases — are  rendered  so  as  the  result  of  gonorrhea  in  the  parents. 

"  Now  as  to  the  method  of  avoiding  the  disease  and  its  dire  results. 
Without  doubt  the  safest  and  best  plan  is  to  avoid  illicit  intercourse. 
Sexual  intercourse  I's  by  )io  t7ieans  essential  to  the  maintenance  of  perfect 
health.  Many  of  the  healthiest  and  best  developed  men  are  those 
who  have  never  had  intercourse  until  they  married. 

"\Mien,  however,  a  man  is  so  unfortunate  as  to  acquire  this  disease, 
he  should  at  once  place  himself  under  the  care  of  a  competent  physician. 
If  this  is  impossible  because  of  lack  of  funds  or  from  other  causes,  he 
should  apply  to  the  nearest  dispensary,  and  remain  under  treatment  not 
only  until  the  discharge  has  ceased, — for  the  disease  is  not  necessarily 
cured  by  that  time, — but  until  the  physician  has  pronounced  him  cured." 

SOME    IMPORTANT    POINTS   TO    OBSERVE    IN   THE   TREATMENT    OF 
GONORRHEA 

1.  Don't  attempt  to  treat  yourself!  You  would  not  attempt  to  treat 
yourself  for  consumption:   it  is  no  easier  to  treat  gonorrhea. 

2.  Don't  be  treated  by  your  friend  or  druggist!  No  two  cases  of  gonor- 
rhea are  exactly  alike,  and  what  cured  your  friend  ma}'  not  cure  you. 

.3.  Don't  allow  yourself  to  be  treated  by  the  quacks  who  advertise  in 
the  newspapers!  These  are  the  worst  kind  of  frauds  and  never  cure 
the  disease.  They  may  arrest  the  discharge  temporarily,  but,  not 
being  properly  cured,  the  disease  returns  in  a  few  weeks  or  months. 

4.  Don't  neglect  the  condition  until  it  becomes  chronic!  It  may  take 
months  or  years  of  treatment  to  cure  if  you  do. 

5.  //  you  hare  had  gonorrhea,  don't  marry  until  you  hare  been  cramined 
by  a  physician  and  have  been  told  that  you  are  icell.  The  disease  may  lurk 
in  the  system  long  after  you  think  you  are  cured. 

(i.  Don't  fail  to  wash  your  hands  thoroughly  after  each  urination  and 
after  each  time  you  touch  the  diseased  jmrts.  Failure  to  do  this  may 
result  in  the  loss  of  an  eye. 

7.  Don't  have  sexual  intercourse  until  you  are  cured.  Not  oiil.v  will 
you  infect  your  partner,  but  you  will  retard  your  cure. 

8.  Be  careful  not  to  infect  water-closets  or  other  objects  from  which 
disea.se  may  be  conveyed  to  innocent  persons. 

The  pamphlet  just  outlined  is  inteiuUnl  for  the  use  of  men,  and  a 
somewhat  modified  one  should  be  prepared  for  the  use  of  women,  es- 
pecially emphasizing  the  danger  to  children  from  sleeping  in  the  same 


168  GONORRHEA    IN    WOMEN 

bed  with  an  infected  mother.  A  pamphlet  somewhat  similar  to  this 
one  was  adopted  in  1908  by  the  State  Board  of  Health  of  Rhode  Island 
and  by  the  American  Public  Health  Association,  and  is  also  employed 
at  the  new  York  hospital  in  Pennsjdvania.  In  Iowa  a  movement  has 
recently  been  instituted  to  place  gonorrhea  and  syphilis  upon  the  same 
footing  with  other  contagious  diseases. 

At  the  present  time  Porto  Rico  and  34  States  and  territories 
have  laws  concerning  ophthalmia  neonatorum.  Kerr^  states  that  the 
State  health  authorities  of  Massachusetts,  Rhode  Island,  New  Jersey, 
and  Vermont  are  specifically  authorized  in  law  to  furnish  prophy- 
lactic outfits  to  physicians  for  use  in  their  practice.  Kerr  states  that 
in  France  ophthalmia  neonatorum  is  classed  as  one  of  the  communic- 
able diseases,  must  be  reported,  and  is  subject  to  disinfection.  In 
Italy  the  regulation  for  midwives  provides  that  the  lids  and  conjunc- 
tivEe  of  infants  must  be  washed  after  birth  with  a  disinfecting  solu- 
tion, and  that  if  inflammation  develops,  a  physician  must  be  called 
immediately.  In  Belgium  a  physician  must  be  called  to  attend  all 
cases  of  ophthalmia  neonatorum,  while  midwives,  before  bathing  the 
infant,  are  required  to  wash  its  eyes  with  sterilized  water.  In  Bavaria 
the  midwife  is  required  to  carry  with  her  a  vial  containing  silver 
nitrate  solution,  with  directions  for  use.  In  Austria  a  penalty  is  pro- 
vided for  midwives  failing  to  call  a  doctor  in  cases  of  ophthalmia 
neonatorum.     Similar  regulations  are  in  force  in  Switzerland. 

'  Kerr,  J.  W.:  Ophthalmia  Neonatorum,  Public  Health  Bulletin  No.  49,  October,  1911, 
Washington,  Government  Printing  Office.  Connecticut:  General  Statutes,  1902,  Sec. 
2535;  district  of  Columbia:  Regulation  for  the  Prevention  of  Blindness,  Sec.  1,  2,  and  3; 
Idaho:  Revised  Codes,  1908,  Sec.  1108;  Illinois:  Chap.  38,  Kurd's  Revised  Statutes,  1909, 
Sec.  510  and  511;  Indiana:  Acts  of  1911,  Chap.  129,  Sec.  1,  2,  3,  4,  and  5;  Iowa:  Acts  of 
1896,  Chap.  57,  Sec.  1,  2,  and  3  (omitted  from  code  of  1897;  Sec.  27,  Chap.  20,  Acts  of  1897, 
declares  that  the  code  is  "the  authoritative  publication  of  the  existing  laws  of  the  State"); 
Kansas:  Resolution,  State  Board  of  Health;  Louisiana:  Sanitary  Code,  1911,  62  (fi),  (b), 
and  (c);  Maine:  Revised  St:iiiitrs.  HKi:;.  ( 'h^ip.  18,  Sec.  90;  Maryland:  Code  of  1904, 
article  27,  Sec.  231;  Massirlius,  ii>.  i;,.M>,.,i  Laws,  1902,  Chap.  75,  Sec.  49  and  50;  also 
Chap.  458,  Acts  of  llilo,  Scr,  I  mihI  l';  .iIm.  A.is  uf  1911,  Chap.  643;  Micliigan:  Compiled 
Laws  of  1897,  Sec.  447;")  and  4l7(i;  Miimr.-nia:  Uctiuhition.  Stale  Hi.ard  of  Health,  Sec.  80 
and  81;  Missouri:  Revisi>il  Suitutes,  l(ili:i.  See.  s:;_'l,  s:;.'_'.  aii^  n:;_':;:  Xelirasku-  Regula- 
tion, State  Board  of  Health,  Rule  L'lC  New  llainpshire:  A.ts  of  I'.lll,  Chap.  121,  See.  1, 
2,  and  3;  New  Jersey:  General  Staiuies.  |s!i.".,  p.  1676,  Sec.  1,  2,  3,  and  4;  also  Acts  of  1911, 
Chap.  96,  Sec.  1  and  2;  New  YfJik;  (  miM.lidated  Laws,  1909,  Chap.  40,  Sec.  482;  also 
Acts  of  1910,  Chap.  513,  Sec.  1;  also  lleaith  Department;  also  State  Department  of  Public 
Health  Manual,  p.  129;  North  Dakota:  Acts  of  1911,  Chap.  188,  Sec.  1,  2,  3,  4,  and  5; 
Ohio:  General  Code,  1910,  Sec.  12787;  Oregon;  Rules  and  Regulations,  State  Board  of 
Health,  1911,  Rules  1  and  3;  Pennsylvania:  Purden's  Digest,  thirteenth  edition,  p.  1886, 
Sec.  78,  79,  80,  and  81;  also  Acts  of  1911,  p.  931,  Sec.  10;  Porto  Rico:  General  Order  No. 
170,  1889;  Sec.  51,  52,  .53,  54,  55,  56,  and  57  (given  force  of  law  by  Sec.  8,  p.  79;  31  Stats.L); 
Rhode  Island:  General  laws  of  1909,  Chap.  343,  Sec.  25,  26,  and  27;  South  CaroHna: 
Criminal  Code,  1902,  Sec.  331;  TennesMi.;  Chap.  10,  Acts  of  1911,  Sec.  1;  Texas:  Acts  of 
1909,  Chap.  :30,  Sec.  10;  Utah:  Aii>.il  lui  I ,  ( 'hap.  61,  Sec.  1;  also  Rules  of  State  Board  of 
Health;  Vermont:  Chap.  220,  Acts  ci  I'.Hd,  .>ec.  1  and  2;  Wisconsin:  Annotated  Statutes, 
1898,  Sec.  1409a  (added  by  Cliai).  59,  Acts  of  1909),  1409a,  1,  2,  3,  and  4.  Reference  to 
decision  rendered  against  individuals  for  infringements  or  lack  of  prophylactic  measures 
.against  ophthalmia  neoiiatcinuu  inav  be  found  under  Cowley  vs.  People,  83  N.  Y.  464, 
and  Peojjle  vs.  Pierson,  176  N.  Y.,  201. 


PROPHYLAXIS  169 

Earh'  in  1911  the  London  Council  issued  an  order  making  ophthal- 
mia neonatorum  a  reportable  disease.  Thus,  as  in  cases  of  specific 
fevers,  immediately  on  diagnosis  a  case  must  be  reported  to  the  health 
officer.  The  object  is  that  more  effectual  means  may  be  taken  for  its 
prevention  and  treatment.  Several  smaller  towns  have  also  adopted 
this  measure.  This  is  characteristic  of  the  attitude  taken  by  most 
English-speaking  races  toward  venereal  disease.  If  we  recognize  the 
infectious  nature  of  ophthalmia  neonatorum,  how  much  more  neces- 
sary is  it  that  a  similar  recognition  should  be  given  to  gonorrhea 
in  adult  patients  who  are  up  and  about  and,  for  many  other  reasons, 
are  more  likely  to  spread  the  disease. 

The  New  York  Board  of  Health  now  requires  the  registration  of 
venereal  disease  in  persons  treated  in  pubhc  institutions,  and  requests 
all  physicians  to  furnish  similar  information  concerning  private  pa- 
tients under  their  care,  permitting  the  names  and  addresses,  however, 
to  be  withheld.  Such  reports  are  considered  confidential.  The  De- 
partment of  Public  Health  also  provides  facilities  for  free  bacterio- 
logic  and  serum  tests,  for  venereal  diseases,  when  data  required  for 
the  registration  of  the  case  are  furnished.'  California  and  Vermont 
require  registration  of  gonorrhea,  which  is  carried  out  by  number  and 
not  by  name.  This  is  a  step  in  the  right  direction.  Individual  rights 
should  not  be  allowed  to  take  precedence  over  public  welfare. 

Nearly  all  the  increase  in  the  eflficiency  of  public  hygiene  has  been 
attained  by  educational  methods.  No  better  way  of  directing  the 
attention  of  the  laitj'  to  the  ravages  of  venereal  disease  could  be 
adopted  than  by  the  formulation  of  a  universal  law  requiring  the  regis- 
tration of  this  class  of  maladies. 

Professor  Coplin,  ex-director  of  Public  Health  of  Pliiladelphia,  is 
of  the  opinion  that  all  male  and  female  venereal  patients  that  are 
likely  to  spread  their  infection  should  be  forcibly  controlled.  In 
Massachusetts  there  is  a  statute  (Chapter  75,  Section  48)  to  the  effect 
that  an  inmate  of  a  public  charitable  or  penal  institution  who  has 
syphilis  in  a  contagious  form  shall,  at  the  expiration  of  his  or  her 
term,  subject  to  the  opinion  of  the  physician  in  charge,  be  detained 
until  such  time  as,  in  the  physician's  opinion,  the  said  person  is  no 
longer  contagious.  There  is  no  reference  to  gonorrhea.  Like  Eng- 
land, the  United  States  has  no  law  against  infecting  others  with 
venereal  disease,  as  shown  by  the  recent  decision  of  the  Sujjreme  Court 
of  Mississippi. - 

'  Ptnn,  .Med.  Jour.,  .\pril,  1912,  p.  581 

'  AuHtin  vg.  State  (Miss.),  56  So.  R.  345;  also  Jour.  Aincr.  Mcil.  A.-isor.,  Ai)ril  i:5,  1912, 
p.  1U2. 


170  GONORRHEA    IN    WOMEN 

An  unusual  case  in  point  was  that  reported  by  Dr.  Isadore  Dyer,  of 
New  Orleans,  before  the  Brussels  Conference  on  the  Prevention  of 
Venereal  Diseases  in  1899— a  patient  with  primary  syphilis  who 
refused  even  charitable  treatment,  and  carried  a  book  wherein  she 
kept  a  record  of  the  number  of  men  she  had  inoculated.  When  she 
was  first  seen  she  declared  that  the  number  had  reached  219,  and  that 
she  would  not  be  treated  until  she  had  revenge  upon  500  men. 

The  system,  as  already  described  in  the  chapter  on  Prostitution,  of 
making  venereal  disease  reportable,  as  adopted  by  Norway,  has  been, 
in  that  country,  extremely  successful.  In  the  large  standing  army 
of  Germany  there  are  frequent  medical  examinations,  during  which 
especial  attention  is  directed  toward  venereal  disease.  If  such  cUsease 
is  detected,  the  patient  is  sent  to  a  hospital  for  treatment  and  deten- 
tion. Too  much  stress  cannot  be  placed  upon  the  necessity  of  entirely 
curing  gonorrhea,  as  the  increase  of  the  affection  is  due  directly  to  the 
number  of  uncured  cases.  Physicians  are  sometimes  to  blame  for  allow- 
ing patients  to  discontinue  treatment  before  they  are  entirely  cured,  and 
for  not  making  thorough  tests  to  ascertain  this  beyond  question. 
It  is,  however,  a  fact  that  there  are  not  a  few  general  practitioners 
who,  because  of  lack  of  knowledge  or  facilities,  are  unable  to  make 
such  tests,  and  this  is  especially  the  case  in  dealing  with  female  gon- 
orrheics.  It  must  always  be  remembered  that  chronic  gonorrhea  is 
the  most  potent  factor  in  the  spread  of  this  disease.  At  this  stage  tlie 
symptoms  are  often  mild,  and  the  diagnosis  in  either  the  male  or  the 
female  is  difficult.  The  most  painstaking  efTort  should  be  made 
entirely  to  eradicate  the  disease.  In  some  medical  schools  venereal 
diseases  are  not  thoroughly  taught,  and,  as  a  result,  practitioners  are 
sent  out  who  are  unalsle  properly  to  treat  such  diseases,  and  who  do 
not  realize  the  importance  of  thorough  treatment.  State  boards  should 
emphasize  the  importance  of  venereal  diseases.  Patients  suffering 
from  venereal  disease  are  notoriously  difficult  to  control,  and  this  is 
particularly  true  of  dispensary  patients.  This  doubtless  accounts  for 
many  uncured  cases.  Davis^  records  that  the  number  of  visits  to  a 
clinic  by  450  gonorrhea  patients,  nearly  all  of  whom  were  in  the  acute 
stage,  was  as  follows:  One  or  two  visits,  285,  or  63.4  per  cent.;  three 
to  five  visits,  80,  or  17.8  per  cent. ;  six  or  more  visits,  85,  or  18.8  per 
cent.  Even  supposing  that  the  majority  of  these  patients  went  else- 
where for  treatment,  it  is  obvious  that,  in  a  large  proportion,  the  course 
of  the  disease  must  have  been  prolonged.  The  quacks  and  patent 
medicine  venders  are  also  prolific  sources  of  gleet,  and  should  be  sup- 
pressed for  this,  if  for  no  other,  reason. 

'  Davis,  M.  E.:  Jour.  Anier.  Med.  Assoc,  Xoveinhpr  9,  1912,  p.  16S9. 


PROPHYLAXIS  171 

Marriage  of  Gonorrheics. — The  frequency  with  which  women  are 
infected  by  liusbands  who  beUeve  themselves  cured  is  well  known. 
These  women,  it  has  been  estimated,  constitute  one-third  of  all  the 
married  women  suffering  from  gonorrhea  seen  in  private  practice. 
Occasionally  the  position  is  reversed,  and  the  husband  is  the  innocent 
sufferer,  but  this  is  by  comparisoii  rare.  Morrow'  estimates  that  there 
are  250,000  married  women  in  the  United  States  suffering  from  gon- 
orrhea, a  fact  that  evidences  the  necessity  for  securing  prophylaxis 
in  this  direction.  This  is  an  extremely  conservative  estimate.  The 
frequencj^  of  pelvic  inflammatory  disease  and  sterility  among  married 
women  and  their  etiologic  relationship  to  gonorrhea  are  well  recog- 
nized. Physicians  are  in  many  cases  to  blame  for  not  explaining  more 
thoroughh',  at  the  time  of  the  acute  attack,  the  nature,  chronicity, 
and  dangers  of  the  disease  in  case  of  future  marriage  of  their  patients. 
Patients  who  do  not  continue  ti-eatment  until  cured  are  also  to  be 
censured.  To  safeguard  the  innocent,  it  has  been  suggested  that  each 
partner  should  be  required  to  present  a  medical  certificate  stating  that 
he  or  she  is  free  from  all  contagious  disease  at  the  time  the  marriage 
certificate  is  issued.  As  the  female  is  but  comparatively  rarely  the 
source  of  infection  at  such  times,  and  because  of  the  oiivious  difficulties 
and  unpleasantness  attending  an  examination  under  such  circum- 
stances, it  would  seem  that  a  certificate  from  the  female  should  not  be 
demanded.  With  the  male,  however,  the  condition  is  quite  different. 
The  proportion  of  men  who  have  suffered  from  gonorrhea  prior  to 
marriage  is  very  large,  and  the  necessary  examinations  are  much  less 
embarrassing.  If.  as  has  been  suggested,  venereal  diseases  were  made 
notifiable,  this  in  itself  would  greatly  facilitate  such  prophylaxis  re- 
garding those  who  had  at  any  time  suffered  from  gonorrhea.  Here, 
too,  a  law  making  it  a  punishable  offense  to  communicate  a  venereal 
disease  would  be  of  especial  benefit.  In  1905  the  State  of  Indiana 
passed  a  law  to  the  effect  that  no  person  afflicted  with  atransmissil)le 
disease  shall  be  privileged  to  marry.  The  State  lioard  of  Health  is 
given  discretionary  powers  in  the  execution  ol  this  statute.  They 
propound  questions  to  every  applicant  for  a  marriage  license.  The 
answers  must  be  sworn  to,  and  penalties  prescribed  for  concealment  of 
venereal  disease  under  such  circumstances.  Similar  laws  are  in  force 
in  North  Dakota,  Michigan,  and  in  some  other  of  our  western  States, 
as  well  as  in  Holland  and  Sjiain.  The  Ohio  State  Medical  Association, 
at  its  meeting  in  Cleveland  on  May  IS,  1911,  urged  the  passage  of 
State  Bill  No.  'M,  which  provides  for  the  physical  examination  of  all 

'  Morrow,  1'.  A.:    Social  Disruscs  aii.l  M:irri:in.-,    I'.KM. 


172  GONORRHEA   IN    WOMEN 

men  applying  for  a  marriage  license.'  Similar  legislative  measures  are 
now  being  considered  in  Utah.=  Such  laws,  if  made  general,  would  to 
a  certain  extent  be  evaded,  but  their  moral  effect,  by  calling  attention 
to  the  necessity  of  freedom  from  venereal  disease  in  those  about  to 
marry,  would  be  extremely  beneficial. 

Ethical  Duty  of  Physician  Toward  Gonorrheics. — Professional  se- 
crecy is  one  of  the  oldest  and  most  praiseworthy  assets  of  the  medi- 
cal profession,  and  the  necessity  for  it  has  been  recognized  since  the 
time  of  Hippocrates.  In  the  majority  of  our  States,  as  also  in  most 
foreign  countries,  laws  are  in  force  definitely  to  cover  this  point. 
Article  834,  of  the  Code  of  Civil  Procedure  of  New  York,  reads  as 
follows:  "A  person  duly  authorized  to  practice  physic  or  surgery  shall 
not  be  allowed  to  disclose  any  information  acquired  in  attending  a 
patient  in  a  professional  capacity,  and  which  was  necessary  to  enable 
him  to  act  in  that  capacity."  This  law,  however,  is  not  enforced,  for 
it  does  not  carry  with  it  a  penal  responsibiUty  for  its  violation.  The 
French  law  is  more  severe,  and  prescribes  a  punishment  of  from  one  to 
six  months  in  prison  and  a  fine  of  from  100  to  500  francs.  In  individual 
cases  exceptions  have  been  taken  to  such  laws  both  in  this  country 
and  abroad.  Much  has  been  written  upon  this  subject,  and  there  is  no 
doubt  that  a  physician  should,  under  such  conditions,  be  influenced 
largely  by  the  circumstances  surrounding  the  individual  case.  The 
cases  that  are  usually  the  most  difficult  of  solution  are  those  in  which  a 
man,  known  to  the  phj^sician  to  be  the  victim  of  an  infectious  gonorrhea, 
purposes  to  marry  a  healthy  woman;  in  such  cases  tact,  discretion,  and 
firmness  will  in  most  instances  suffice.  In  a  case  seen  by  Piogey  the 
intended  bridegroom  insisted  on  the  marriage  taking  place,  declaring 
that  the  ceremony  was  absolutely  necessary  because  of  financial  rea- 
sons. He  was  prevented  from  accomplishing  his  crime  only  by  Piogey 
threatening  pubhc  insult  and  a  subsequent  duel.  Such  chivalrous 
methods  are,  of  course,  hardly  necessary  in  this  country,  and  in  more 
than  one  instance  a  jury  has  upheld  a  physician  who  has  interfered 
under  like  conditions.  The  general  trend  of  both  the  professional  and 
the  lay  opinion  seems,  very  rightly,  to  be  toward  a  relaxation  of  strict 
professional  secrecy  under  such  circumstances. 

Personal  Prophylaxis. — This  includes  such  measures  as  may  be 
adopted  by  the  individual,  male  or  female,  either  before  or  after  coitus, 
to  prevent  venereal  infection.  This  subject,  like  that  of  prostitution, 
undoubtedly  has  a  moral  aspect,  and  the  question  whether  we  should 
recommend  means  by  which  infection  may  be  more  or  less  combated. 

»  New  York  Med.  Record,  May  27,  1911. 

^  Bogart,  G.  H.:  Amcr.  .lour.  Dermat.,  January,  1912,  p.  23. 


PROPHYL.\XIS  173 

is  not  unassailable.  '\,Miatever  harm  might  be  wrought  by  the  dis- 
semination of  such  knowledge  among  the  laity,  there  can  be  no  two 
opinions  as  to  the  benefit  to  be  derived  from  such  treatment  in  our 
soldiers  in  the  efficiency  and  defensive  strength  of  our  army  and  navy. 
Perhaps  the  simplest  means  of  securing  personal  prophylaxis  is  by 
urinating  and  washing  or  douching  the  genitaUa  immediately  after  a 
suspicious  intercourse.  Urination  and,  at  the  same  time,  pinching  to- 
gether the  lips  of  the  meatus  so  as  to  insure  thorough  washing  out  of 
the  anterior  urethra,  is  a  common  practice  among  men.  This  simple 
procedure  is  often  effective,  and  the  failure  to  adopt  it  no  doubt  ac- 
counts, to  a  great  extent,  for  the  frequency  with  which  intoxicated  indi- 
viduals, when  exposed,  contract  gonorrhea.  Moller'  states  that  67.7  per 
cent,  of  661  venereal  patients  contracted  their  disease  while  intoxicated. 

Gonococci  develop  most  favorably  on  a  medium  that  is  nearly 
neutral.  The  urine  is  usually  strongly  acid,  as  is  also  the  urethra, 
but  as  a  result  of  sexual  excitement  considerable  mucus  that  is  alka- 
line in  nature  is  thrown  out,  thus  rendering  the  canal  receptive  to  in- 
fection. Hence  infection  is  favored  by  all  conditions  that  stimulate 
the  secretion  of  mucus.  These  include  prolonged  sexual  excitation 
and  local  congestion,  protracted  and  repeated  intercourse,  and  all 
factors  that  retard  the  orgasm,  such  as  intoxication,  etc.  .Alco- 
holic excesses  also  favor  infection  in  other  ways ;  under  such  circum- 
stances withdrawal  is  likely  to  be  delayed,  and,  too,  the  urine  is  more 
irritating  than  normal.  It  is  well  known  that  irritation  of  the  mucosa 
predisposes  to  infection.  The  semen  is  alkaline,  and  hence  tends  to 
produce  a  reaction  in  the  urethra  favorable  for  the  growth  of  the  gono- 
cocci. Probably  the  next  most  well-known  prophj'lactic  agent  is  the 
condom.  This  is  an  almost  certain  means  of  prevention  of  contami- 
nation from  one  partner  to  the  other,  provided  the  condom  has  not 
been  previously  infected  and  is  not  ruptured. 

The  histoiy  of  the  condom  is  somewhat  in  doubt.  Pfister-  States 
that  he  has  found  records  that  indicate  the  em])loyment  of  a  sort  of  penis 
sheath,  or  condom,  by  the  ancient  Egyptians,  some  two  thousand  years 
B.  c.  The  invention  of  this  article  is,  however,  generally  credited  to 
John  Cundum,  an  Englishman,  some  authorities  claiming  that  he  was 
a  physician  in  the  time  of  Cromwell;  others  describe  him  as  a  colonel 
in  the  Guards,'  and  as  living  during  the  reign  of  Charles  II.  However 
that   may  be,  the  condom  attained  almost  inunediate  i)opularitj',  a 

'  Moller,  M.:  Zeitschr.  f.  Bekampf.  d.  Gcschlechtskrankh.,  Leipzig,  vol.  v,  puit  7. 
'Pfister,  E.:  Zeit.  f.  Uroloeie,  Trans.  Uerman  Uroiogical  Coiigrcs-s,  Supplement  No.  3, 
1!»I2. 

'  A  Classical  Dictionary  of  the  Vulgar  Tongue,  178.5. 


174  GONORRHEA    IN    WOMEN 

fact  not  to  be  wondered  at  when  the  prevalence  of  venereal  diseases 
in  England  at  this  period  is  considered.  As  a  result  of  the  unpleasant 
notoriety  which  his  invention  achieved,  the  originator  was  compelled 
to  change  his  name.  The  first  of  these  articles  was  made  from  the 
cecum  of  a  lamb,  by  stripping  out  the  mucous  coat  and  rubbing  the 
skin  with  bran  and  almond  oil  until  it  became  pliable.^  The  fame  of 
these  articles  soon  spread  over  the  civilized  world,  and  we  find  them 
the  subject  of  the  well-known  witticism  attributed  to  a  lady  of  the 
French  court.- 

When  the  gonococcus  is  deposited  on  the  mucous  membrane  of  the 
genital  tract,  it  has  been  found  that  some  hours  must  elapse  before  the 
microorganism  gains  access  to  the  underlying  tissue.  During  this 
period  the  organisms  may  be  washed  off  with  comparative  ease,  and 
if  it  were  not  that  they  often  entered  the  openings  of  small  ducts  or 
mucous  glands,  urination  or  simple  washing  would  be  even  more 
effective  than  it  is.  The  gonococcus  is  quite  easily  destroyed  by  anti- 
septics, especially  the  silver  salts,  and  it  is  upon  these  two  facts  that 
the  prophylactic  treatment  now  so  generally  adopted  in  the  navy  is 
based. 

Owing  to  the  extreme  prevalence  of  venereal  diseases  in  the  army 
and  the  navy,  the  medical  officers  of  both  departments  have  been 
forced  to  adopt  measures  tending  to  check  the  ravages  of  these  dis- 
eases among  the  troops.  Effective  personal  prophylaxis  can  be  more 
thoroughly  instituted  in  the  navy  than  in  the  army.  In  the  former  the 
following  scheme  was  attempted :  When  the  men  returned  after  leave 
of  absence  (shore  leave),  they  were  asked  if  they  had  been  exposed  to 
infection,  and  if  they  would  care  to  take  prophylactic  treatment. 
This  treatment  was  found  to  be  so  successful,  and  the  proportion  of 
men  who  developed  venereal  disease  after  such  prophylaxis  was  so 
small  that  the  system  was  finally,  at  least  on  most  ships,  made  com- 
pulsory. On  the  U.S.S.  Ranger  the  methods  of  carrying  out  the 
prophylactic  measures  are  explained  by  the  following  rules: 

1.  All  men,  immediately  upon  return  from  shore,  shall  at  once 
report  to  sick  bay. 

2.  If  they  have  been  exposed  to  venereal  infection,  they  will  at 
once  take  treatment. 

3.  If  they  report  themselves  as  not  having  been  exposed  to  such 
infection,  a  record  is  kept,  and  should  such  a  man  subsequently  de- 
velop venereal  disease,  he  will  be  reported  as  having  disobeyed  orders. 

'A  matron  named  Phillips,  at  Half  Moon  Street,  in  theStnni.l,  made  a  fort  imp  from  the 
manufacture  of  those  little  articles.  She  retired  for  a  time,  and  li;i\  iiil;  s.|uandered  her 
fortune,  agam  took  up  their  manufacture,  which  proved  so  successful  thai  she  was  again 
enabled  to  retire  in  1776. 

-  "A  cuirass  against  pleasure  and  a  cobweb  against  danger." 


PROPHYLAXIS  175 

4.  The  sick  bay  will  be  open  for  treatment  from  7  to  9.30  a.  m. 
Men  returning  from  liberty  at  unusual  hours  or  whose  duties  prevent 
them  from  reporting  at  the  time  may  receive  treatment  at  any  time. 

The  following  instructions  were  posted  in  the  sick  bay : 

1.  Before  coming  to  sick  bay  m-inate  and  wash  well  with  water. 

2.  In  the  sick  bay  wash  well  with  the  solution  (bichlorid  1  :  2000). 

3.  Use  half  a  syringeful  of  the  injection,  and  retain  it  in  the  canal 
for  three  minutes.  (The  solution  consists  of  3  per  cent,  protargol 
and  15  per  cent,  glycerin.  The  glycerin  causes  the  protargol  to  ad- 
here to  the  mucous  membrane.  About  1  c.c.  is  injected,  so  as  to  reach 
the  first  inch  of  the  urethra  only.) 

■4.  Rub  the  ointment  (30  per  cent,  calomel)  well  into  the  whole 
penis,  and  leave  it  on  for  two  hours. 

The  results  of  this  treatment  were  as  follows:  Number  of  liberties, 
39.  Number  of  men  on  Uberty,  949.  Number  of  men  exposed,  256. 
Number  of  men  not  exposed,  693.     Result,  no  venereal  disease. 

This  includes  liberties  in  10  different  ports,  many  of  which  were 
well  known  to  be  rife  with  venereal  disease. 

A  less  elaborate  but  efficient  form  of  chemical  i)rophylaxis  was 
recommended  b\'  Hausmann'  in  1885.  This  author  instilled  a  few 
drops  of  a  2  per  cent,  solution  of  silver  nitrate  into  the  urethra  after 
coitus.  This  method  was  later  indorsed  by  Ulmann,-'  Blokusewski,' 
Porosz,'  Neisser,'  and  P'rank.*'  The  latter  devised  a  portable  dropper 
to  be  used  for  this  purpose. 

In  1899  P'rank'  performed  an  interesting  experiment,  tending  to 
show  the  efficacy  of  the  prophylactic  treatment.  The  urethras  of  6 
men  were  inoculated  with  gonococci  and  3  with  3  to  5  drops  of  a  20 
per  cent,  protargol  solution.  These  3  escaped,  while  those  not  treated 
developed  a  specific  urethritis. 

The  results  obtained  on  the  U.S.S.  Ranger  as  regards  prophylaxis 
against  venereal  diseases  are  merely  confirmatory  of  those  obtained  on 
the  U.8..S.  Concord,  on  which  shij),  of  28 1  known  exposures  followed 
by  the  adoption  of  prophylactic  measures,  there  resulted  only  two 
cases  of  venereal  disease,  both  of  which  had- exceeded  their  time  al- 
lowance on  shore,  and,  as  a  result,  treatment  had  been  delayed.  The 
connnanding  officer  of  the  Concord  states  that  during  the  first  five 
months  in  which  these  i)roi)hyIactic  measures  were  in  force  tiicre  was 

'  lliiiisin:inn:    DciilsiOi.  iiiimI.  Wocli..  ISS.j,  No.  25. 

2  Ulmann:   Wicii.  iiic.l.  HiJitlcr,  ()cl(il)rr  2H,  1897. 

'  Bloku.sowski :  Dcut.scli.  mod.  Wocli.,  1,H9.5. 

'  Porosz:  Monuts.  f.  Urol.,  vol.  ix,  No.  2,  p.  09. 

'  Neisser:   Deutsch.  Me<lieinal-Ztg.,  190.5,  No.  (i9. 

'  Frank:  Wien.  mod.  AVoeli.,  19()1,  No.  S. 

'  Frank:  Allg.  nied.  CVnl.-Zeitung,  1899,  No.  .5. 


176  GONORRHEA    IX    AVOMEN 

not  a  single  case  of  either  gonorrhea  or  syphilis  contracted  by  the  crew. 
Henry'  states  that  on  the  U.S.S.  Rainbow,  of  529  admitted  exposures, 
there  were  four  cases  of  gonorrhea;  one  of  these  failed  to  receive  treat- 
ment, and  two  others  were  treated  more  than  twelve  hours  after  ex- 
posure; if  these  cases  are  excluded,  there  remains  a  percentage  of 
0.189.  On  board  the  Charleston,  in  the  Philippines  and  in  China, 
3828  individual  liberties  were  granted,  of  which  number  437  failed  to 
report,  and  of  these,  32  developed  venereal  disease;  1396  admitted 
exposures  were  treated;  of  these,  only  one  developed  a  disease.  The 
Culgo,  at  Colombo,  Ceylon,  had  25  exposures,  which  were  followed  by 
prophylactic  measures;  no  venereal  disease  resulted.  On  board  the 
Baltimore,  on  the  Asiatic  station,  visiting  Sydney,  Melbourne,  and 
Auckland  for  one  month  each,  with  prophylaxis  there  was  "practically 
no  venereal  disease,"  whereas  the  British  ships,  in  the  same  environ- 
ment, had  over  25  per  cent,  of  their  crew  infected.  On  the  Baltimore, 
at  Marseilles,  the  exposures  were  estimated  at  2280;  of  these,  13  de- 
veloped gonorrhea,  only  two  of  these  receiving  treatment.  On  this 
ship  the  list  of  men  on  liberty  was  sent  to  sick  bay,  and  on  their  return 
they  reported  at  sick  bay  and  were  checked  off.  If  a  man  was  under 
the  influence  of  liquor,  he  was  sent  to  sick  bay  in  charge  of  a  messenger. 
On  the  Tacome  educational  measures  were  attempted,  but  failed  la- 
mentably, and  forced  prophylaxis  was  instituted.  Of  756  men  exposed 
and  treated  by  prophylactic  measures,  none  developed  venereal  dis- 
ease. On  the  Virginian,  the  following  instructive  results  were  ob- 
tained. For  oije  quarter  (three  months)  no  prophjdaxis  was  attempted 
and  30  cases  of  venereal  disease  developed.  Optional  prophylactic 
measures  were  instituted  for  two  quarters  (of  three  months  each) ,  and 
resulted  in  the  development  of  23  cases  of  venereal  disease  for  the  first 
quarter  and  41  cases  for  the  second  quarter.  During  the  last  quarter 
compulsory  prophylaxis  was  in  force,  and  there  were  13  cases  of  ven- 
ereal disease.  During  the  latter  period  1178  men  admitted  exposure 
and  were  given  treatment.  Of  these,  5  developed  venereal  disease. 
The  remaining  8  had  denied  exposure  and  had  not  received  treatment. 
Ledbetter-  reports  from  Cavite,  Philippine  Islands,  a  station  in  which 
venereal  diseases  are  prevalent,  that  prophylactic  measures  have  re- 
duced these  diseases  markedly.  Previous  to  their  introduction  the 
percentage  of  venereal  diseases  of  all  classes  among  the  men  averaged 
from  25  per  cent,  to  30  per  cent,  annually,  and  at  times  even  higher. 
The  percentage  of  gonorrhea  has  been  reduced  to  8  per  cent,  annually, 
and  this  includes  many  patients  who  did  not  receive  treatment.     Rat- 

'  Henry,  R.  B.:  Assoc.  Military  Surgeons  U.  S.,  Twentieth  Annual  Meeting,  September 
26-29,  1911. 

=  Ledbetter:  Jour.  Amer.  Med.  Assoc,  April  15,  1911,  p.  1098. 


PROPHYL.\XIS 


177 


ing  on  a  similar  basis,  chancroids  were  reduced  from  5  per  cent,  to  2 
per  cent.,  and  sypliilis  from  about  20  cases  annually  to  one  case  in 
1910. 

At  the  naval  station  in  New  Orleans,  the  voluntary  plan  of  prophy- 
laxis proved  ineffective,  and  compulsorj^  methods  were  adopted.  Of 
500  men  treated,  no  venereal  diseases  resulted.  On  the  Salem,  5300 
liberties  were  granted,  and  6  cases  of  venereal  disease  resulted.  Two 
of  these  delayed  treatment  and  3  did  not  receive  treatment  at  all. 
On  the  Georgia,  7494  liberties  were  granted  and  5500  treatments  insti- 
tuted; 33  cases  of  venereal  disease  resulted,  and  10  of  these  followed 
delayed  treatment.  On  the  Rhode  Island,  on  the  trip  home  with  the 
battleship  fleet  from  IManila,  all  men  returning  from  liberty  were  given 
prophylactic  treatment,  with  excellent  results. 

Henry'  has  employed  calomel,  50  grams,  liquid  petrolatum,  SOc.c, 
and  lanolin,  70  grams,  as  a  prophjdactic  on  529  men  who  admitted  ex- 
posures; 0.189  per  cent,  developed  infection  thi-ough  failure  of  the 
treatment.  This  wTiter  further  states  that  of  a  crew  of  nearly  200, 
there  was  not  a  single  case  of  gonorrhea  at  the  time  of  writing,  a  con- 
dition unknown  prior  to  the  introduction  of  prophylactic  measures. 

In  the  Atlantic  fleet  the  voluntarj'  system  is  still  in  operation  on 
many  ships.  During  June  and  July  there  were  53G5  acknowledged  ex- 
posures and  treatments  among  a  total  of  about  121,000  liberties.  Of 
429  cases  of  venereal  disease,  only  105  followed  treatment,  or  a  little 
less  than  2  per  cent,  of  known  exposures.  Coml)ined  reports  from  the 
Asiatic  Station  covering  1909,  with  70,954  liberties  and  21,100  ad- 
mitted exposures,  show  599  cases  of  venereal  di.sease,  of  which  176, 
or  0.83  per  cent.,  received  prophylactic  treatment.  The  prophylactic 
report  of  February,  1910,  including  the  delaj'ed  Januarj'  report  from 
the  \'illalobos,  showed  1714  admitted  exposures  among  9408  liberties. 
Among  the  entire  crew  there  were  57  cases  of  venereal  disease.  The 
prol)al)l('  cause  given  is  as  follows: 


Failed  to  rejiort .  .  . 
Denied  exposure .  . 
Overwt;iyin«  liberty 
ExieiiiliMl  liberty.  . 
Treated  early.  .  . .  . 
Treated  late 


Cases 

GoNOKRHEA 

15 

13 

4 

3 

1 

1 

lit 

10 

10 

4 

8 

5 

Peuckntaqe 

Based  un 
Total  Cases 


26.30 
7.01 
1.70 
33.33 
17..54 
14.04 


Failures  of  treatment,  based  on  number  reporting  and  treated  on  time:    Number  of 
cases,  10;  percentage,  0.04;  number  of  cases  of  gonorrhea,  4;   percentage,  0.20. 

'  Henry,  R.  B.:   Military  Surgeon,  May,  1912,  p.  590. 


178  GONORRHEA   IN   WOMEN 

The  fleet  surgeon  states  that  many  of  these  infections  occurred  in 
men  in  whom  treatment  was  delayed.  He  adds  that  "There  is  no 
reason  to  think  that  a  sense  of  security  engendered  by  the  scheme 
(prophylaxis)  has  caused  any  increased  indulgence."  Gates  sum- 
marizes resiilts  as  follows:  Of  8516  known  exposures,  plus  an  unknown 
number  of  exposures  from  nearly  20,000  additional  liberties,  57  cases 
developed  after  treatment,  whereas  166  cases  appeared  among  the  un- 
treated. Of  the  total  number  of  cases  of  venereal  disease,  less  than 
20  per  cent,  developed  among  those  who  had  received  prophylactic 
treatment.  The  treatment  on  board  ships  varies  but  little,  and  con- 
sists of  washing  with  soap  and  water  and  urinating  before  reporting  at 
sick  bay.  In  sick  bay  the  following  procedure  is  adopted :  Wash  in 
soap  and  water;  then  in  bichlorid  1  :  1000  or  1  :  2000  for  five  min- 
utes. Inject  from  1  to  5  c.c.  of  protargol,  2  per  cent,  to  3  per  cent.; 
or  argyrol,  5  per  cent,  to  10  per  cent.,  and  retain  the  same  in  the  ure- 
thra for  from  three  to  ten  minutes  by  the  clock.  After  drjdng,  apply 
Metchnikoff's  calomel  ointment  (33  per  cent,  to  50  per  cent,  calomel, 
made  with  lanolin  or  petroleum  or  mixtures  of  these). 

Maus'  recommends  an  ointment  containing  30  per  cent,  calomel  and 
3  per  cent,  phenol  in  lanolin.  This  maj'  be  put  up  in  collapsible  tubes, 
which  are  convenient  and  cheap.  The  ointment  is  rubbed  thoroughly 
over  the  entire  penis  and  adjacent  parts,  and  allowed  to  remain  for 
two  or  more  hours.  In  some  cases,  if  the  men  are  to  go  on  duty  at 
once,  the  ointment  is  covered  with  a  light  dressing.  The  men  are  in- 
structed not  to  urinate  for  a  couple  of  hours  after  receiving  treatment. 
The  author's  experience  has  been  confirmed  by  that  of  Ledbetter,^  who 
prefers  argyrol  to  protargol  for  the  urethral  injection,  since  the  former 
is  less  irritating  and  more  efficient.  It  may  be  employed  as  a  10  per 
cent,  to  25  per  cent,  solution.  The  addition  of  a  little  glycerin  is 
beneficial,  as  it  causes  the  mixture  to  adhere  to  the  urethral  mucosa. 
In  some  cases  2  per  cent,  protargol  solution,  if  retained  in  the  urethra 
for  five  minutes,  causes  pain  and  discomfort  for  some  hours  after  the 
treatment.  The  consensus  of  opinion  among  the  medical  officers  of 
the  navy  is  that  if  this  treatment  is  thoroughly  administered  within 
eight  hours  of  exposure,  protection  is  almost  certain;  if  within  twenty- 
four  hours,  it  is  of  great  value,  and  should  be  employed  even  up  to 
forty-eight  hours;  later  than  this,  however,  it  is  of  little  use.  In  the 
navy  the  treatment  is  given  not  by  the  surgeon,  but  by  hospital  at- 
taches and  enlisted  men  of  the  naval  corps.  This  is  due  to  the  fact 
that  returning  liberty  parties  on  large  ships  sometimes  number  250 

>  Maus,  L.  M.:  Quoted  by  J.  M.  Phalen,  The  Post- Graduate,  AprU,  1912,  p.  225. 
^Ledbetter:  Jour.  Amer.  Med.  Assoc,  April  15,  1911,  p.  109S. 


PROPHYL.\XIS  179 

men.  Compulsory  measures  are  not  adopted  universally  in  the  navy, 
but  are  subject  to  the  approval  of  the  commanding  officer.  In  addi- 
tion to  the  medical  prophylactic  treatment,  educational  methods  are 
in  force  on  many  ships,  the  men  being  instructed  regarding  the  fre- 
quency and  dangers  of  venereal  disease  during  the  first-aid  instruction. 
In  the  German  navy  prophylactic  packages  are  on  sale  at  a  nominal 
price.  Failure  to  use  the  treatment  is  regarded  as  a  military  offense. 
The  packages  are  small,  and  contain  practically  the  same  articles  used 
in  the  United  States  navy.  Prophylactic  measures  are  also  in  force  in 
the  Japanese  and  French  navies.  Mummery^  advocates  their  employ- 
ment in  the  British  navy,  and  believes  that  if  such  measures  were 
adopted,  venereal  disease  would  be  reduced  75  per  cent. 

In  the  army  the  conditions  attending  garrison  life  are  not  so  favor- 
able for  the  enforcement  of  personal  venereal  prophylaxis  as  in  the 
navy,  and  this  doubtless  accounts  for  the  fact  that  such  measures  have 
not  been  so  widely  adopted.  Nevertheless,  these  have,  to  a  certain 
extent,  been  attempted,  and  where  introduced,  have  produced  good 
results.  Huff=  recommends  that  a  package  be  prepared  whose  con- 
tents are  similar  in  general  character  to  those  used  in  the  navy;  that 
these  be  distributed  gratuitously  by  the  army  medical  corps,  and  that 
they  be  placed  on  sale  at  post  exchanges.  A  similar,  but  less  effective, 
prophylactic,  known  as  the  "K"  package,  is  now  in  use  at  some  posts! 
The  "K"  package  contains  a  dram  vial  of  a  20  per  cent,  protargol 
solution  in  glycerin,  or  a  10  per  cent,  aciueous  solution  of  argvrol,  and 
a  medicine-dropper.  Accompanying  the  kit  is  a  pamphlet  giving 
dn-ections  for  use.  Raymond^  reports  that  of  576  men  to  whom  "K" 
packages  were  issued,  only  three  cases  of  gonorrhea  resulted.  All  the 
infected  men,  however,  used  the  solution  improperly  (i.  e.,  one  or  two 
days  after  exposure).  This  method  of  prophylaxis  has  been  of  great 
service  m  some  stations  in  the  Philippines,  where  venereal  diseases 
are  so  rife.  Wilson^  reports  that  at  Camp  Stotsenburg,  Philippine 
Islands,  enforced  prophylaxis  has  been  adopted.  Every  man  who  is 
exposed  is  required  to  take  the  treatment.  If  he  fails  to  do  so,  he  is 
court-martialed  and  punished.  The  treatment  is  somewhat  similar 
to  that  employed  in  the  navy,  and  consists  in  urination,  washing  with 
soap  and  water,  followed  by  the  injection  of  a  10  per  cent,  solution  of 
argyrol,  which  is  held  in  the  urethra  for  five  minutes.  As  a  last  step, 
30  per  cent,  calomel  ointment  is  ai^plicd.  Wilson  believes  that  by  this 
method  00  per  cent,  of  venereal  disea.ses  may  be  prevented.  He  gives 
the  following  reasons  for  preferring  this  method  to  the  distribution 

J  Mummery:  Brit.  Med.  Jour.,  August  15,  I'JOS,  p.  .304. 

•  HiifT:   Military  .Surgeon,  1909,  p.  7.>t.         »  Uaymonil:  Military  .Surgeon,  1909,  p.  733. 
WiLsoti:   .Military  Surgeon,  February,  1911,  p.  102. 


180  GONORRHEA   IN   WOMEN 

of  the  prophylactic  package :  (1)  The  patient  receives  treatment  under 
the  supervision  of  a  man  who  understands  the  method.  (2)  The  pa- 
tient is  sober  and  treatment  is  thoroughly  and  properly  administered. 
(3)  Many  men  are  not  sober  at  the  time  of  exposure,  and  either  use  the 
package  treatment  improperly  or  throw  the  package  away  without 
using  it.  (4)  This  method  is  more  economic,  as,  with  proper  man- 
agement, no  waste  should  occur.  (5)  A  full  record  can  be  kept,  and 
as  a  result  accurate  statistics  can  be  obtained.  The  disadvantage  is 
that  more  time  must  elapse  before  treatment  is  applied.  The  army 
method  is,  for  many  reasons,  less  effective  than  the  measures  in  force 
in  the  navy,  and  the  "K"  package  further  lacks  the  antisyphilitic 
and  bactericidal  properties  possessed  by  the  Metchnikoff  ointment. 

Feistmantel'  relates  an  interesting  prophylactic  experiment:  640 
soldiers  were  divided  into  three  groups:  one  group  received  no  in- 
struction regarding  prophylaxis,  and  approximately  5.8  per  cent,  were 
infected.  Another  group  were  simply  instructed  to  urinate  and  wash 
the  genitalia  with  soap  and  water  after  coitus;  about  4  per  cent,  of 
these  were  infected.  The  third  group  were  given  regular  prophylactic 
treatment,  and  about  2  per  cent,  were  infected.  None  of  the  men  who 
received  prophylactic  treatment  within  three  hours  of  coitus  were 
infected.  Zieler-  emphasized  the  importance  of  personal  prophylaxis, 
and  gives  minute  du-ections  how  the  treatment  should  be  carried  out. 
He  also  urges  that  phj^sicians  should  constantly  inculcate  the  necessity 
for  thorough  daily  cleansing  of  the  external  genitalia  in  both  sexes, 
even  in  children.  The  multiplicity  of  secreting  glands  and  the  putre- 
faction of  the  secretions  are  likely  to  induce  irritation  and  minute 
lesions  which  open  portals  to  infection  of  all  kinds.  Guiard'  recom- 
mends thorough  washing  out  of  the  entu-e  anterior  urethra  with  a 
solution  of  potassium  permanganate  as  a  prophylactic  against  gon- 
orrhea. Apart  from  the  actual  prophylactic  properties  of  both  the 
navy  and  the  army  methods,  these  are  of  value  simply  by  calling  atten- 
tion to  the  prevalence  of  venereal  disease.  Phalen,'*  in  referring  to  the 
situation  in  the  army,  states  that  the  voluntary  use  of  the  "K"  package 
has  accomphshed  but  little,  and  that  the  problem,  as  it  now  exists,  is 
rather  administrative  than  professional,  and  depends  upon  getting  the 
exposed  individual  and  the  prophylactic  remedy  together. 

Personal  prophylactic  measures  are  in  force  in  the  Japanese  and 
French  armies.     The  German  forces,  while  abroad,  are  usually  sub- 

'  Feistmantel:  Wien.  med.  Woch.,  1905,  Nos.  13  to  17. 

'  Zieler,  K.:  Deut.  med.  Woch.,  Berlin,  February  22,  1912,  vol.  xxx\-iii.  No.  S,  p.  345. 
'  Guiard,  F.  P:  Jour,  de  med.  de  Paris,  1911,  vol.  xxiii,  p.  175;  also  Rev.  prat,  d, 
d.  org.  gen.-urin.,  Paris,  1911-12,  vol.  viii,  p.  46. 

«  Phalen,  J.  M.:  The  Post-Graduate,  April,  1912,  pp.  255-261. 


H 


PROPHYLAXIS  181 

jected  to  compulsory  prophylactic  treatment.  Tandler^  states  that 
prophylactic  measures — injections  of  10  per  cent,  to  20  per  cent,  of 
protargol — were  employed  1560  times  in  an  arm}'  detachment  of  170 
men,  and  resulted  in  a  50  per  cent,  reduction  of  venereal  disease.  In 
the  Austro-Hungarian  army  the  experiment  Avas  made  of  issuing  tab- 
lets of  5  per  cent,  formalin  soap  to  men  about  to  go  on  leave  of  absence. 
It  has  been  suggested  that  small  packages,  with  directions  for  use  and 
containing  such  articles  as  are  in  vogue  in  the  navy,  be  placed  on  sale 
at  drug-stores  for  general  use.  IVIoral  arguments  may  be  adduced 
against  such  a  procedure,  but  are  hardly  to  be  considered  as  repre- 
hensible as  the  present  ^"ide  sale  of  condoms.  These  last  are,  of  course, 
purchased  with  malice  aforethought,  whereas  medical  prophjdaxis 
offers  a  means  of  preventing  an  infection  in  one  who  has  perhaps  not 
expected  to  yield  to  temptation.  Moral  arguments  against  the  use  of 
medical  prophj-laxis  can  be  based  onh'  upon  the  supposition  that 
venereal  disease  is  the  punishment  for  transgression — an  obsolete  and 
Puritanical  view  that  is  detrimental  to  any  cause,  and  that,  carried 
further,  would  intimate  that  no  attempts  should  be  made  to  cure 
venereal  patients.  If  the  prophjdactic  properties  of  such  packages 
were  generally  known,  their  sale  would  go  far  toward  reducing  the 
prevalence  of  venereal  disease  among  men,  and,  therefore,  among 
women.  It  seems  to  have  been  well  proved  that  this  type  of  prophy- 
laxis can  be  used  with  gi-eat  advantage  by  men.  It  is  most  efficient 
against  gonorrhea  and  syphilis.  On  account  of  the  short  incubation 
period  of  chancroid,  this  form  of  prophylaxis  is  less  satisfactory  when 
dealing  with  this  disease.  For  anatomic  reasons,  a  prophylaxis  such 
as  the  foregoing  is  of  less  .service  in  the  female.  Nevertheless,  a  some- 
what modified  form  could  be  applied  in  many  cases,  and  might,  with 
advantage,  be  combined  with  other  hygienic  methods,  such  as  douch- 
ing, etc.,  now  ad\-ise(l  for  prostitutes  in  those  countries  where  regula- 
tion is  in  force. 

In  attempting  pr()i)hylaxis  of  a  disease  as  prevalent  as  gonorrhea, 
and  one  hedged  about  with  so  many  difficulties,  moral,  civic,  and  i)er- 
sonal,  no  one  .system  can  be  effectual.  The  two  important  points  to 
be  desired  are  the  protection  of  the  uninfected  and  the  cure  of  the 
di.sea.sed.  We  should  not  be  hampered  by  moral  doubts  and  plati- 
tudes, but  should  endeavor  to  utilize  every  known  source  to  check  this 
dreaded  lesion.  It  is  only  by  i)utting  forth  our  strongest  efforts  that 
any  hope  of  ultimate  success  can  be  harbf)red.  We  should  realize  that 
there  is  no  one  ideal  projihylactic  against  gonorrhea,  and  that  different 
methods  are  re(|uired  to  reach  different  i)eopl(>.     Fear  is  undoubtedly 

'TiiiKllcr:    DcT  Mililiinuzl,  XovciiiImt  ir,,  lOO.j. 


182  GONORRHEA   IN   WOMEN 

one  of  the  most  efficient.  Educational  methods  will  not  control  the 
criminal  class,  among  whom  venereal  disease  is  frequent.  It  is  true 
that  educational  measures  may  protect  the  next  generation,  but 
they  will  not  prevent  those  now  infected  from  disseminating  their  dis- 
ease. No  methods  should  be  branded  as  inefficient  unless  they  have 
been  definitely  proved  to  be  so.  Too  much  should  not  be  expected  in  a 
short  time,  as,  owing  to  the  character  of  venereal  disease,  and  of  gon- 
orrhea in  particular,  httle  can  be  hoped  for  except  bj'  a  prolonged 
effort.  Germany  has,  during  the  last  few  years,  awakened  to  the 
necessity  of  action  in  this  direction,  and  the  scientific  world  can  study 
with  advantage  the  results  of  her  numerous  and  efficient  systems. 
It  is  impossible,  however,  to  compare  Germany  with  the  United  States. 
The  character  of  the  people,  their  surroundings,  their  educational 
methods,  and  the  moral  teachings  there  inculcated  are  all  radically 
different  from  those  existing  in  this  country.  Prophylaxis  is,  at  best, 
largely  a  matter  of  money,  and  the  necessary  means  of  raising  funds  to 
carry  on  such  a  campaign  lies  largely  with  the  charitable  institutions, 
with  individuals,  and  with  the  municipal  authorities. 

BIBLIOGRAPHY 

Diehl:  United  States  Naval  Med.  Bull.,  1910,  p.  325. 
Eytinge:  Military  Surgeon,  1909,  p.  170. 
Keys:  New  York  Med.  Jour.,  June  29,  1907,  p.  1201. 
Oakley:   Cleveland  Med.  Jour.,  February,  1911. 
Spear:  United  States  Naval  Med.  Bull.,  1910,  p.  146. 
Zalesky:  United  States  Naval  Med.  Bull.,  1910,  p.  28. 
Amer.  Jour.  Public  Health,  1908,  pp.  65,  70. 


CHAPTER  VIII 
THE  EXAMINATION  OF  PATIENTS 

The  examination  of  patients  for  the  i)urpose  of  detecting  the  pres- 
ence of  gonorrhea  may  be  divided  into  four  distinct  stages:  History 
taking;  inspection  of  the  suspected  region;  palpation;  and  bacteriologic 
examination 

Anamnesis. — The  case  history  should  include  the  age  of  the  patient; 
general  previous  hist  or}';  menstrual  history;  marital  history,  which 
should  include  data  regarding  pregnancies,  miscarriages,  abortions,  or 
sterilit}'  (relative  or  absolute);  the  existence  of  leukorrhea,  and  anj^ 
subjective  symptoms  from  which  the  patient  may  be  suffering.  Es- 
pecial attention  should  be  directed  to  the  menstrual  history,  inquiries 
being  made  concerning  changes  in  the  character  of  the  flow  and  the 
presence  of  dj^smenorrhea.  The  question  of  conception  is  also  an 
important  one  in  this  connection.  Gonorrhea  frequently  results  in 
sterility;  occasionally',  however,  one  or  more  children  will  be  born,  but 
an  attack  of  sepsis  followed  by  steriUty  is  very  suggestive  of  a  Neisser- 
ian  infection.  Careful  inquiry  should  be  made  regarding  the  occur- 
rence of  ophthalmia  in  the  children,  as  its  presence  is  an  almost  certain 
indication  of  gonorrhea  in  the  mother.  Leukorrhea  is  also  an  impor- 
tant symptom.  An  increase  in  the  amount,  and  particularly  a  change 
from  the  ordinary  whitish  discharge  to  a  thick  yellowish  or  purulent 
flow,  is  a  manifestation  not  to  be  overlooked,  especially  if  this  change  in 
the  character  of  the  flow  has  followed  marriage  or  a  suspicious  inter- 
course. Iiujuiries  should  also  be  instituted  concerning  the  existence 
of  vesical  irrital)ility,  frequency  of  urination,  dysuria,  and  cloudiness 
of  the  urine.  The  i)ossibility  of  previous  attacks  of  i)elvic  jjeritonitis, 
as  well  as  of  dyspareunia,  painful  defecation,  etc.,  should  Ije  incjuired 
into.  In  eliciting  information  much  tact  is  necessary,  and  especial 
care  should  be  taken  to  avoid  wounding  the  patient's  .sensibilities.  If 
the  patient  is  a  married  woman,  the  questions  should  be  so  framed  as  to 
be  entirely  free  from  all  suggestion  of  marital  contamination. 

Preparation  of  the  Patient  for  a  Gynecologic  Examination.  In 
making  an  office  examination,  the  ])hysician  should  safeguard  himself 
by  having  a  reliable  thij-d  person  present.  If  he  employs  an  oflice 
niM-se,  her  presence  is  sufficient;    if  not,  the  patient  slioiiM  lie  dircctc)! 

|S1 


184  GONORRHEA    IN    WOMEN 

to  bring  an  elderly  woman,  preferably  her  mother  or  an  older  sister, 
with  her.  The  day  Ijefore  the  examination  the  bowels  should  be  thor- 
oughly moved  by  a  cathartic.  In  general  gynecologic  work  it  is  usually 
customary  to  instruct  the  patient  to  urinate  just  before  coming  for 
examination.  When  gonorrhea  is  suspected  the  patient  should  be 
instructed  not  to  urinate  for  four  or  five  hours  previous  to  the  examina- 
tion, so  that  if  a  purulent  discharge  is  present  in  the  urethra,  its  pres- 
ence may  be  noted  and  an  abundant  amount  obtainable  for  the  bac- 
teriologic  examination.  After  cultures  or  smears  have  been  taken,  the 
bladder  may  be  emptied.  For  similar  reasons  the  patient  should  not 
take  a  vaginal  douche  before  being  examined. 

Examination  Table. — This  should  be  so  arranged  as  to  secure  a 
good  light.  This  is  a  very  important  point.  Although  daylight  is 
preferable  to  artificial  light,  the  latter  is  so  much  more  certain  as  to  be 
almost  a  necessity.  Care  should  be  observed  to  select  a  powerful 
light,  but  one  that  can  be  so  arranged  as  not  to  shine  in  the  eyes  of  the 
physician  during  the  course  of  the  examination.  A  toilet  and  special 
examining  room  is  of  great  advantage,  insuring  privacy  for  the  patient 
both  before  and  after  the  examination.  If  this  is  not  available,  the 
examining  table  should  be  completely  screened  off  from  the  rest  of  the 
room.  The  patient  should  be  directed  to  loosen  all  clothing  about  the 
waist  and  to  remove  the  corsets.  This  is  necessary  not  only  for  the 
abdominal  examination  which  usually  precedes  the  pelvic  examina- 
tion, at  least  in  all  new  cases,  but  is  essential  for  the  making  of  a  satis- 
factory pelvic  investigation. 

The  variety  of  examining-table  to  be  used  is  largely  a  matter  of 
preference.  A  table  that  is  moderately  high,  that  inclines  slightly 
away  from  the  examiner,  and  that  permits  the  patient  to  get  on  and 
off  without  difficulty  is  most  to  be  desired.  The  top  should  be  well 
padded,  but  not  soft.  One  or  two  firm  pillows  are  almost  a  necessity. 
One  of  these,  placed  under  the  patient's  head,  not  only  adds  greatly  to 
her  comfort,  but  tends  to  relax  the  abdominal  muscles.  A  jaillow  may 
also  be  used  to  elevate  the  pelvis  when  the  patient  is  in  either  the  dorsal 
or  Sims'  position.  The  examining-table  should  contain  a  drawer  for 
holding  instruments,  or  a  special  small  table  may  be  utilized  to  hold 
them,  as  well  as  the  various  medications  and  tampons,  etc.,  that  are 
likely  to  be  required.  Great  care  should  be  exercised  throughout  the 
entire  examination  to  avoid  unnecessary  exposure  of  the  patient. 
For  this  purpose  one  or  two  sheets  are  usually  employed.  These 
should  be  so  draped  as  to  permit  the  examiner  to  make  a  thorough  in- 
spection, with  as  Uttle  exposure  of  the  patient  as  possible.  Indeed,  if 
this  part  of  the  examination  is  cleverly  performed,  the  patient  rarely 


THE    EX,\MINATION    OF    PATIENTS  185 

knows  that  she  has  been  exposed  at  all.  It  is  absolutely  essential, 
howe\'er,  that  a  thorough  inspection  be  obtained. 

Instruments  and  Lubricants  Required  in  Making  a  Gynecologic 
Examination. — For  the  ordinary  pelvic  examination  the  instruments 
necessary  are  two  tri valve  or  bivalve  specula  of  different  sizes,  a 
Sims'  speculum,  a  double  tenaculum  forceps,  a  pair  of  long,  stout 
dressing  forceps,  and  four  applicators.  The  last  are  used  for  securing 
specimens  for  bacteriologic  examination,  a  fresh  instrument  being 
used  in  each  location.  This  is  done  to  obviate  the  danger  of  carrying 
infection  from  one  area  to  another.  If  the  operator  has  a  small  al- 
cohol lamp  at  hand,  one  applicator  will  be  sufficient,  its  point  being 
sterilized  in  the  flame  each  time  it  is  employed.  Small  slivers  of  steri- 
lized wood  (tooth-picks,  for  example)  may  be  substituted  for  the  metal 
applicators.  These  may  be  held  with  a  pair  of  applicating  forceps 
while  in  use,  their  ends  being  covered  with  sterile  cotton.  The  wooden 
applicators  should  be  used  only  once  and  then  destroj'ed.  \\lien  there 
is  a  sufficient  amount  of  secretion,  and  in  all  cases  of  vaginitis  in  chil- 
dren, the  best  instrument  for  securing  material  for  bacteriologic  ex- 
amination is  a  medicine-dropper,  or  a  small  glass  syringe  to  the  end  of 
which  a  small  soft-rubber  nozle,  about  an  inch  or  two  in  length,  has 
been  attached. 

Van  Gieson'  has  compared  the  results  obtained  by  the  use  of  cotton 
swabs  with  those  secured  by  using  the  medicine-dropper,  and  finds 
that,  with  the  latter,  a  considerably  larger  proportion  of  positive  re- 
sults were  olitained.  This  is  due  to  the  fact  that  with  the  swab  method 
the  solid  particles  of  secretion  are  caught  in  the  fibers  of  the  cotton, 
with  the  result  that  the  material  placed  ujion  the  cover-glass  consists 
largely  of  serum.  The  mechanical  trauma  incident  to  attempting  to 
transfer  the  discharge  on  the  swab  to  the  slide  is  often  suflicient  to 
injure  or  destroy  the  leukocytes  or  epithelial  cells,  thus  making  the 
detection  of  the  gonococci  and  their  intracellular  demonstration  more 
difficult.  The  intracellular  establishment  is  an  essential  feature  in 
the  rccnfriiiticjn  of  the  organism.  Apart  from  this,  removal  of  thick, 
tenacious  material,  such  as  is  found  in  the  cervix,  from  the  swab 
to  the  slide,  is  usually  difficult.  The  application  of  the  swab  is  also 
usually  painful,  and  in  cases  of  vaginitis  in  children  frequently  harm- 
ful. On  the  other  hand,  a  medicine-dropi)er  with  a  small  .soft-rubber 
nozle  can  be  easily  and  i)ainlessly  introduced  into  the  vagina.  If 
the  secretion  is  scant\'  and  cultures  are  not  to  be  taken,  the  medicine- 
dropper  may  be  partially  filled  with  Ijichlorid  solution,  1 :.")()()().  This 
is  introduced  into  the  vagina  of  the  child,  and,  by  c(mii)ressing  and 

'VanGioson:   MpiJ.  Rcconl,  June,  HtlO. 


186  GONORRHEA   IN   WOMEN 

expanding  the  bulb  a  few  times,  an  emulsion  of  the  exudate  is  formed. 
Another  advantage  of  this  method  is  that  by  it  the  entire  vaginal 
contents  may  be  obtained.  The  liichlorid  fixes  the  cellular  elements, 
and  when  dried  on  the  slide,  they  are  of  perfect  form.  If  necessary, 
the  collected  fluid  may  be  centrifuged.  This  method  is  also  useful 
in  securing  material  from  cases  of  ophthalmia.  \^^ienever  possible, 
in  obtaining  material  for  bacteriologic  examination  from  adults,  the 
pipet  should  be  substituted  for  the  swab. 

An  excellent  instrument  for  obtaining  a  specimen  of  the  suspected 
secretion  from  women  is  a  blunt-pointed,  dull,  narrow-bladed  bistoury. 
The  small  sharp  spoons  now  made  also  answer  the  purpose  admirably. 
Dufaux^  has  devised  a  little  instrument  for  this  purpose;  it  is  shaped 
like  a  finger,  and  answers  the  same  purpose  in  forcing  out  the  con- 
tents of  the  glands,  whereas  the  back  is  hollowed  out  to  catch  the 
droplet  of  secretion  expressed. 

It  is  sometimes  advisable  to  collect  the  secretion  for  examination 
in  thin  glass  or  capillary  tubes,  sealing  the  ends  of  the  same  over  the 
flame.  The  exudate  thus  secured  may  be  employed  for  making  cul- 
tures or  smear  preparations.  For  cultures  it  is  inferior  to  direct  in- 
oculation. To  make  the  smears,  clean  glass  microscopic  slides  are 
required.  These  are  best  kept  in  a  70  per  cent,  alcohol  solution, 
which  sterilizes  and  keeps  them  clean  and  from  which  they  may  be 
taken  for  use  as  required.  WTien  cultures  are  to  be  made,  test-tubes 
containing  the  media  and  four  platinum  loops  with  which  to  obtain 
the  suspected  secretion  are  necessary.  In  the  ordinary  case,  these 
instruments  will  suffice.  When,  however,  it  is  found  necessary  to 
examine  the  bladder,  cystoscopic  instruments  will  be  required.  In  a 
case  of  unruptured  hymen  a  large  or  medium-sized  cj'stoscope  may 
be  used  through  which  to  inspect  or  treat  the  cervix  or  vaginal  walls. 
This  is  also  of  use  in  making  examinations  of  the  urethra  in  cases  of 
ulcers,  localized  areas  of  inflammation,  strictures,  or  chronic  ure- 
thritis. 

For  rectal  examination,  a  proctoscope  will  also  be  required.  The 
type  of  instruments  employed  is  largely  a  matter  of  individual  choice 
with  the  operator.  Electric  batteries  can  now  be  obtained,  from 
which  hghts  may  be  introduced  not  only  through  the  cystoscope  and 
proctoscope,  but  also  through  the  ordinary  vaginal  speculum.  These 
lights  are  often  of  great  assistance.  The  routine  employment  of 
rubber  gloves  is  an  advantage.  Not  only  is  the  danger  of  infection 
to  both  patient  and  operator  minimized  by  their  use,  but  the  surgeon's 
hands  are  spared  the  frequent  hard  scrubbings  and  long  immersions 

'  Dufaux:    Deut.  mod.  Wopli.,  Berlin,  1912,  vol.  xxxviii,  No.  5. 


\ 


THE    EX.\MINATI0X"  OF    PATIENTS  187 

in  antiseptic  solutions,  which  have  a  tendency'  to  roughen  the  skin  and 
make  its  steriUzation  more  difficult.  Their  use  also  tends  to  save 
much  time.  An  operator  soon  becomes  accustomed  to  wearing  rubber 
gloves,  and  learns  to  palpate  quite  as  accurately'  with  them  as  with 
the  bare  hand.  But  one  glove  need  be  worn,  the  hand  on  the  abdomen 
being  left  bare.  Gloves  are  best  put  on  dry  after  sprinkling  powder 
inside  them,  care  being  taken,  however,  not  to  allow  an  excess  of  powder 
to  be  deposited  in  the  tips  of  the  index-  and  middle  glove-fingers,  as 
the  latter  will  impair  the  tactile  sense.  All  instruments  and  gloves 
should  be  sterilized  before  being  used. 

Excellent  lubi-icants  are  now  manufactured  I)y  most  of  the  physi- 
cians' supply  houses.  These  are  stored  in  a  convenient  form  in  col- 
lapsible metal  tubes.  The  chief  requisites  of  a  lubricant  are  that 
it  be  easy  of  application,  non-irritating,  water-soluble,  non-greasy, 
non-corrosive  to  instruments,  aseptic,  and  easily  removable  from  the 
hands.  Glycerin  is  a  good  lubricant,  and  is  soluble  in  water.  Vaselin 
and  other  grea.sy  substances  exhibited  in  cups  or  wide-mouthed  bottles 
should  be  avoided,  because  of  the  danger  of  contaminating  the  cups 
and  thus  inoculating  subsequent  patients.  This  objection  may  be 
overcome  by  sterilizing  a  number  of  small  \\ade-mouthed  bottles  of 
vaselin  and  using  a  separate  bottle  for  each  case.  At  best,  vaselin  is 
not  a  satisfactory  lubricant. 

Position  for  Examination  and  Local  Treatment. — The  position 
in  which  the  patient  is  to  be  placed  upon  the  table  varies  with  the 
case.  In  this  country  the  dorsal,  or  hthotomy,  position  is  the  most 
popular,  whereas  in  England  the  Sims'  left  lateral  position  is  very 
generally  employed.  It  is  in  onl}'  rare  instances  that  it  will  be  found 
necessary  to  use  the  knee-chest  or  other  postures.  The  dorsal  position 
varies  somewhat  according  to  the  table  that  is  employed.  The  most 
satisfactory  tables  are  those  having  stirrups  in  which  to  place  the  feet. 
These  stirrups  are  on  a  level  with,  or  shghtly  above,  the  table,  and 
are  arranged  on  a  movable  arm,  so  that  the  position  of  the  foot-support 
may  be  ])laced  either  nearer  to,  or  farther  from,  the  table,  to  suit  the 
comfort  and  convenience  of  the  patient.  If  bimanual  paljiation  is 
difficult,  further  relaxation  may  be  obtained  l^y  flexing  the  thighs 
upon  the  abdomen.  This  is  known  as  the  gluteodorsal  position,  and 
may  be  attained  either  by  having  an  assistant  support  the  limbs  or 
by  placing  the  patient's  feet  in  elevated  supports,  such  as  are  usually 
employed  for  plastic  operations.  At  the  same  time  the  jiatient's 
l)Uttocks  should  be  brought  well  down  over  tlic  edge  of  the  table. 
When  the  patient  is  to  be  placed  on  the  table  in  tlic  dorsal  position, 
the  clothing  should  be  loosened  about  t  he  wai.st.     The  nurse  or  operator 


188  GONORRHEA    IN   WOMEN 

takes  a  position  in  front  of  the  patient,  placing  a  sheet  so  that  it  will 
extend  from  her  chest  to  the  floor.  The  patient  should  stand  im- 
mediately in  front  of  the  examining  table,  and  be  instructed  to  raise 
her  clothing  to  the  waist,  and  then  to  sit  on  the  edge  of  the  table. 
Next  she  lies  down  on  the  table,  and  her  feet  are  raised  and  placed  in 
stirrups.  The  sheet  should  at  all  times  entirely  cover  the  patient. 
A  pillow  is  then  placed  under  the  patient's  head,  and  the  sheet  so 
arranged  as  to  expose  the  genitaUa.  The  examination  should  then 
be  proceeded  with  in  a  routine,  systematic  manner. 

Method  of  Performing  Routine  Examination  and  of  Obtaining 
Material  for  Bacteriologic  Investigation. — The  external  genitalia 
should  first  be  inspected,  giving  special  attention  to  any  inflammations, 
reddened  areas,  ulcers,  or  papillomata  that  may  be  present.  The 
amount  and  character  of  the  discharge  should  be  ascertained.  The 
condition  of  the  hymen  should  be  determined,  for  although  the  in- 
tegrity of  this  membrane  is  not  an  absolute  proof  of  virginity,  the 
fact  that  it  is  ruptured  is  strong  presumptive  evidence  of  unchastity 
in  the  unmarried. 

The  next  point  to  be  examined  is  the  opening  of  Bartholin's  glands. 
The  vulvovaginal  glands,  as  they  are  termed  by  Huguier,  are  the 
analogue  of  Cowper's  glands  in  the  male,  and  are  situated  in  the  lower 
and  posterior  portion  of  the  labia  majora.  They  are  rounded  struc- 
tures, somewhat  flattened  anteroposteriorly,  and  vary  in  size,  even 
in  the  same  individual.  Usually  the  glands  are  about  the  size  of  an 
almond,  and  in  thin  women  they  can  often  be  felt  as  a  distinct  thick- 
ening; in  stout  patients,  in  those  who  have  not  reached  puberty,  and 
in  old  age,  palpation  of  these  structures  is  usually  impossible,  ^^^len, 
however,  an  infection  is  present,  the  glands  can  easily  be  outlined 
from  the  surrounding  parts  by  their  hardness  and  induration. 

Frecjuently,  in  bartholinitis,  only  the  duct  of  the  gland  is  involved. 
The  orifice  of  the  duct  is  situated  about  0.5  cm.  in  front  of  the  hymen, 
or  carunculse  myrtiformes,  as  the  case  may  be,  and  at  a  point  slightly 
below  the  junction  of  the  middle  and  lower  third  of  the  labia  minora, 
on  the  inner  surface  of  these  structures.  The  duct  is  about  1  or  2  cm. 
in  length.  Inflammation  of  any  type,  involving  either  the  gland  or 
its  duct,  causes  a  reddening  about  the  opening.  Inflammations  of 
these  regions  are  nearly  always  gonorrheal  in  origin.  The  tj^pical 
macula)  gonorrhoicse  of  Sanger  consist  of  reddened,  elevated  areas 
about  3  to  5  mm.  in  diameter,  firmer  than  the  surrounding  tissue,  and 
somewhat  resembling,  in  appearance,  a  mosquito-bite  or  flea-bite, 
the  extreme  center  being  dark  red  and  elevated.  Frequently,  how- 
ever, the  only  evidence  of  infection  is  a  slight  reddening  or  discolora- 


THE    EXL'i.MINATION    OF    PATIENTS  189 

tion  about  the  orifice  of  tlie  duct.  In  those  cases  in  which  gonorrhea 
is  suspected  the  labia  should  be  retracted,  and  the  inner  surface  wiped 
dry  with  a  piece  of  sterile  cotton.  Pressure  should  then  be  made 
directly  over  the  gland,  downward  and  outward,  milking  the  gland 
and  duct  throughout  their  entire  length.  In  the  normal  individual, 
if  this  has  been  properly  performed,  a  small  drop  of  clear  mucus  will 
be  extruded  from  the  gland  opening.  If  this  secretion  is  turbid  or 
purulent,  infection  may  be  strongly  suspected.  A  clear  discharge  is 
not,  however,  positive  proof  of  the  absence  of  gonorrhea.  Smears 
should  be  made,  or  cultures  taken  from  the  secretion  of  both  sides, 
and  labeled  B.  R.  and  B.  L.,  according  to  the  side  from  which  they 
have  been  obtained,  or  the  operator  may  make  a  routine  habit  of 
examining  various  points  in  succession,  and  number  the  slides  accord- 
ingly. Thus  Xo.  1  would  invariably  indicate  the  secretion  from 
Bartholin's  gland  on  the  right  side;  No.  2,  from  that  on  the  left,  and 
so  on.  The  urethra  should  next  be  examined,  particular  attention 
being  directed  toward  reddening  of  the  external  urinary  meatus.  The 
external  orifice  should  be  wiped  dry  with  sterile  cotton,  and  the  urethra 
milked  rather  vigorously  throughout  its  course.  The  secretion  thus  ob- 
tained may  be  used  for  making  smears  and  cultures,  these  being  labeled 
'"U"  or  No.  3.  In  chronic  cases  the  gonococci  are  most  frequently 
found  in  Skene's  ducts,  which  are  situated  in  the  floor  of  the  urethra, 
just  within  the  orifice.  In  the  multipara  the  openings  of  these  ducts 
are  usually  readilj^  seen,  but  in  women  who  have  not  borne  children  it 
sometimes  becomes  necessary  to  dilate  the  external  minary  meatus 
slightly  before  a  good  exposure  can  be  obtained.  If  infection  is 
I)resent,  these  structures  can  usually  be  discerned  as  small,  reddened 
pits  from  which,  when  pressure  is  exerted  beneath  them,  a  small  drop 
of  pus  often  exudes.  In  order  to  secure  secretion  from  them  for 
bacteriologic  examination  a  small  probe  may  be  used  gently  to  scrape 
the  floor  of  the  urethra  over  Skene's  ducts,  and  in  suspicious  cases 
it  may  be  inserted  a  short  distance  into  the  glands  themselves.  A 
capillary  tube,  with  a  small  bulb  attached  to  one  eiul  to  effect  drainage 
of  the  exudate  into  the  tube,  is  also  an  excellent  instrument  to  use  for 
this  purpcse.  All  such  material  may  be  set  aside  and  labeled  '"S". 
The  next  organ  to  be  examined  is  the  cervix.  To  do  this  the  labia 
should  be  separated  and  wiped  dry  with  sterile  cotton,  to  avoid  the 
clanger  of  carrying  infection  from  the  external  genitalia  to  deeper, 
l)erhaps  uninfected,  organs.  If  cultures  are  not  to  be  taken,  tlie  ex- 
ternal genitalia  and  inner  sides  of  the  labia  are  best  s])onged  with  a 
1:1()()()  bichlorid  solution.  Anti.septics  should  not  be  employed  if 
•  uiturcs  arc  to  ix-  taken,  for  their  use  ma>'  iiiliiliit   i)acterial  growth. 


190  GONORRHEA    IN   WOMEN 

The  cervix  is  now  exposed  through  a  suitable  specukmi.  The  bivalve 
or  trivalve  speculum  is  usually  employed  for  this  purpose;'  it  should 
be  introduced  with  the  edges  parallel  to  the  long  axis  of  the  body,  and 
after  it  has  been  inserted  an  inch  or  two,  rotated.  When  inserting 
any  instrument  into  the  vagina,  it  is  important  to  make  the  necessary 
pressure  backward  toward  the  rectum,  rather  than  forward  or  later- 
ally. Before  attempting  to  open  the  speculum  it  should  be  pushed 
in  as  far  as  is  necessary,  going  somewhat  downward  and  posterior  to 
the  supposed  location  of  the  cervix.  A  non-observance  of  this  detail 
will  permit  the  anterior  vaginal  wall  to  roll  out  in  front  of  the  cervix 
and  obstruct  the  view  of  this  structure.  'Wlien  possible,  it  is  best  to 
ascertain  the  position  of  the  cervix  by  the  touch  before  introducing 
the  speculum.  The  cervix  being  exposed,  its  general  appearance  is 
observed,  its  size  and  the  character  of  the  discharge  noted,  as  well  as 
the  presence  of  any  areas  of  inflammation.  Of  especial  significance 
in  the  nulhpara  is  a  reddened  area  immediately  surrounding  the  ex- 
ternal OS.  This  is  occasionally  simulated  by  a  congenital  erosion  of 
the  cervix,  but  this  condition  is  easily  differentiated  from  a  gonorrheal 
cervicitis.  The  cervix  should  next  be  swabbed  with  bits  of  sterile  cotton, 
the  thick,  tenacious  mucus  that  is  present  at  the  external  os  being  re- 
moved as  thoroughly  as  possible.  A  single  smear  or  culture  may  now 
be  taken  from  the  secretion  just  within  the  external  os.  The  cervical 
canal  should  now  be  dried  further  by  means  of  small  pledgets  of  sterile 
cotton.  It  is  important  that  as  much  mucus  as  possible  be  removed 
from  the  canal.  '  The  cervix  is  now  best  fixed  with  a  double  tenaculum, 
and  squeezed  firmly  either  with  the  fingers  or  with  forceps,  or  the  lower 
portion  of  the  canal  may  be  slightly  dilated,  the  material  for  bacterio- 
logic  examination  being  then  removed  from  a  point  well  within  the  cer- 
vical canal.  Firm  compression  of  the  cervix  is  made  in  order  to  obtain-, 
the  secretion  from  the  cervical  glands  and  from  the  deeper  crypts  of  the 
canal,  areas  in  which,  in  chronic  cases,  the  gonococci  are  particularly 
likely  to  linger.  The  specimen  thus  obtained  may  be  labeled  "  C  "  when 
it  was  taken  from  the  cervix,  or  "C.  C."  when  obtained  from  the  cer- 
vical canal.  If  the  patient  to  be  examined  is  a  A'irgin,  the  intra  vaginal 
manipulations  can  usually  be  performed  through  a  large-sized  cysto- 
seope,  without  resulting  injury  to  the  hymen.  In  these  cases  it  is 
sometimes  best  to  administer  an  anesthetic.  After  having  obtained  a 
specimen  for  bacteriologic  examination  from  the  vulvovaginal  glands, 
urethra,  and  cervix,  the  usual  pelvic  examination  may  be  made,  especial 
attention  being  directed  toward  detecting  adhesions  of  the  uterus  or 
its  appendages,  and  enlargements  or  lesions  of  the  latter. 

Asepsis  in  Gynecologic  Examination. — In  all  forms  of  gynecologic 


THE    EXAMINATION    OF    PATIENTS  191 

work  strict  asepsis  must  be  maintained.  This  applies  to  examina- 
tions and  treatments,  as  well  as  to  operations.  In  making  the  routine 
examination  laxity  regarding  asepsis  will  result  not  only  in  contamina- 
tion of  many  previously  uninfected  cases,  but  will  prove  a  bar  to 
successful  treatment.  'N^Tiere  a  number  of  cases  are  to  be  examined 
in  succession,  infection  is  particularly  likely  to  occur  unless  thorough 
asepsis  is  carried  out.  Although  the  routine  use  of  rubber  gloves 
does  much  to  lessen  this  hkelihood,  the  observance  of  the  usual  pre- 
cautions should  not  be  neglected.  Before  each  case  is  examined  the 
hands  should  be  washed  and  immersed  in  an  antiseptic  solution.  All 
instruments  and  dressings  should  be  sterilized.  A  good  plan  is  to 
have  two  sets  of  examining  instruments,  one  set  being  allowed  to  boil 
while  the  other  set  is  in  use. 

Sims'  Left  Lateral  Position. — Xot  infrequently,  for  purposes  of 
inspection  or  for  obtaining  specimens  for  bacteriologic  examination, 
the  patient  is  placed  in  Sims'  left  lateral  position.  This  posture 
has  the  advantage  of  being  less  tiresome  for  the  patient  than  the 
dorsal  position,  but  when  palpation  is  to  be  performed,  the  former 
position  is  much  inferior  to  the  latter.  In  the  Sims'  position  the 
patient  lies  on  her  left  side,  with  the  knees  flexed  nearly  at  a  right 
angle  with  the  thighs,  the  latter  "being  similarly  flexed  on  the  abdomen; 
the  right  leg  is  more  markedly  flexed  than  the  left,  and  the  pelvis  is 
tilted  so  that  the  right  knee  rests  above  the  left  and  on  the  table.  If 
the  table  is  a  narrow  one,  the  left  arm  may  be  allowed  to  hang  over 
the  edge;  if  not,  the  arm  should  lie  behind  the  back.  The  trunk 
should  be  so  rotated  as  to  bring  the  breasts  in  contact  with  the  table. 
A  firm  pillow  placed  beneath  the  pelvis  increases  the  inclination  of 
the  latter  and  is  often  of  assistance.  The  examiner  may  now  proceed 
in  the  usual  manner,  except  that  a  Sims'  speculum  is  substituted  for 
the  bivalve  type.  If  the  patient  is  placed  properlj'  in  the  left  lateral 
position,  the  vagina  will  balloon  out  with  air  as  soon  as  the  speculum 
is  introduced.  An  exception  to  this  may  be  found  in  patients  suffering 
from  extensive  pelvic  adhesions. 

Knee-chest  Position. — In  rare  instances  it  maj*  be  found  advisable 
to  place  the  patient  in  the  knee-chest  posture.  When  this  is  done, 
the  patient  assumes  the  attitude  of  Eastern  supplication,  except  that 
the  face  is  turned  to  one  side.  The  knees  are  brought  to  the  edge  of 
the  table,  the  thighs  being  perpendicular.  Success  in  both  the  knee- 
chest  and  the  Sims'  position  depends  on  the  proper  tilting  of  the  pelvis, 
which  will  permit  the  intestines  to  gravitate  out  of  it;  as  a  conse- 
(luence,  when  the  speculum  is  introduced,  the  vagina  becomes  filled 
with  air.     In  both  positions  it  is  essential  that  the  spiii(>  be  relaxed 


192  GONORRHEA   IN   WOMEN 

and  the  back  bent  forward.  The  knee-chest,  or,  as  it  is  sometimes 
termed,  the  genupectoral  position,  is  so  trying  for  the  patient  that 
it  is  rarely  employed  in  ordinary  examinations.  By  its  use,  however, 
an  excellent  exposure  of  the  entire  vagina  and  cervix  may  be  secured. 
For  ordinary  purposes  the  dorsal  position  is  the  preferable  one,  and 
if  a  table  that  permits  the  lower  end  to  be  elevated  is  employed,  the 
intestines  will  gravitate  out  of  the  pelvis  almost  as  well  in  this  posi- 
tion as  in  either  the  Sims'  or  the  knee-chest  posture. 

Examination  of  Patients  in  Bed. — Under  some  circumstances  it 
may  be  necessary  to  examine  patients  in  bed.  In  such  cases  the 
woman  should  be  turned  on  her  side,  and  the  buttocks  lifted  well  over 
the  edge  of  the  bed,  the  limbs  being  supported  by  assistants  or  allowed 
to  rest  on  chairs.  A  pillow  should  be  placed  under  the  head.  For 
purposes  of  palpation  only  the  patient  may  lie  on  her  back  at  the  side 
of  the  bed,  covered  with  a  sheet  and  with  her  knees  drawn  up.  The 
examiner  sits  on  a  chair  beside  the  bed,  to  the  left  or  right,  according 
to  the  hand  he  is  accustomed  to  employ  in  making  vaginal  examina- 
tions. Bed  examinations  are,  as  a  rule,  much  less  satisfactory  than 
are  those  performed  on  an  examining  table. 

Methods  of  Palpation. — In  performing  palpation  of  the  pelvic 
organs,  many  methods  are  employed  for  securing  relaxation  of  the 
patient's  abdominal  and  pelvic  muscles.  On  introducing  the  fingers 
into  the  vagina,  pressure  should  be  directed  backward,  and  every 
effort  made  to  avoid  manipulation  of  the  clitoris.  The  utmost  gentle- 
ness is  essential  if  a  satisfactory  palpation  of  the  intraperitoneal 
generative  organs  is  to  be  made.  When  a  patient  complains  of  pain 
or  tenderness  on  one  side,  it  is  best  to  examine  the  opposite  side  first, 
for  by  palpating  the  diseased  area  at  once,  the  patient  will  involuntarily 
contract  her  muscles,  and  thus  render  the  remainder  of  the  examina- 
tion more  difficult.  One  of  the  best  procedures  for  securing  relaxa- 
tion of  the  abdominal  muscles  is  to  have  the  patient  take  deep  breaths 
and  keep  the  mouth  open.  It  is  essential  to  gain  the  confidence  of  the 
patient,  for  if  she  is  frightened  and  fearful  of  being  hurt,  relaxation  is 
rarely  obtainable.  For  this  reason  the  first  steps  in  the  exaixiination, 
especially  if  it  is  the  first  examination,  should  be  performed  with  the 
utmost  gentleness,  and  if  it  is  necessary  to  palpate  tender  structures, 
this  should  be  done  last. 

Sonnenfeld'  directs  that  the  patient  clasp  her  hands  and  pull 
vigorously.  This  will  help  to  distract  her  attention  from  the  examina- 
tion, and  thus  facihtate  the  latter.  It  has  been  suggested  that  in 
cases  in  which  there  is  marked  rigidity  over  the  lower  abdomen,  pressure 
be  made  slightly  above  the  umbilicus  by  means  of  a  broad  leather 

1  Sonnenfeld:  Monats.  f.  Geb.  u.  Gyn.,  1910,  vol.  xxxii,  p.  572. 


THE    EXAMIXATIOX    OF    PATIENTS  193 

strap  or  sheet  twisted  into  a  rope  for  five  or  ten  minutes,  by  which 
procedure,  it  is  claimed,  the  recti  muscles  become  tired  and  relaxation 
is  obtained. 

Structures  can  often  be  more  easily  palpated  if  the  cervix  is  grasped 
with  a  double  tenaculum  forceps  and  drawn  downward  toward  the  vagi- 
nal outlet.  By  placing  his  foot  on  a  stool  or  on  the  rung  of  a  chair, 
resting  the  elbow. of  the  examining  hand  on  his  knee,  or  by  pressing 
his  elbow  against  his  side,  the  operator  will  be  enabled  to  dispense 
with  much  of  the  muscular  effort  of  the  forearm  that  is  usuallj^  re- 
quired in  making  an  examination,  and  that  interferes  with  the  fine 
sense  of  touch.  Examinations  should  be  conducted  in  a  routine, 
systematic  manner,  each  organ  in  turn,  whether  diseased  or  not,  being 
palpated. 

The  Use  of  Anesthesia  in  Gynecologic  Examination. — In  cases 
that  present  any  especial  difficulties  in  the  way  of  making  a  thorough 
examination  or  formulating  a  diagnosis,  and  whenever  an  adult  pa- 
tient is  presumably  a  virgin,  an  anesthetic  should  be  employed. 

Rectal  Examination. — Whenever  it  is  deemed  necessary  to  follow  a 
vaginal  examination  by  a  rectal  one,  the  danger  of  carrying  infection 
from  the  genitalia  to  the  bowel  must  be  borne  in  mind.  The  perineum 
and  anus  should  be  carefully  cleansed  with  an  antiseptic  solution,  and 
clean  gloves  and  instruments  employed. 

Rectal  examinations  are  of  especial  value  to  the  gynecologist  in 
examining  those  patients  in  whom  the  hj-men  is  intact.  Not  in- 
fre(iuentlj'  deeply  placed  structures  can  be  more  definitely  outlined 
through  the  rectum  than  through  the  vagina.  It  is  possible,  by  this 
method,  to  examine  the  posterior  surface  of  the  uterus. 

Bacteriologic  Examination. — The  next  step  in  the  examination 
is  the  staining  of  the  smear  preparations.  This  can  best  be  deferred 
until  after  the  patient's  departure.  In  all  cases  in  which  microorgan- 
isms resembling  the  gonococci  are  detected  the  Gram  method  of  staining 
should  be  employed.  In  medicolegal  cases,  and  especially  in  suspected 
cases  in  which  the  findings  have  repeatedly  been  negative,  cultures 
.should  be  made.  In  bacteriologically  negative  cases  that  present 
clinical  .symptoms  of  gonorrhea  repeated  examinations  should  be  made 
in  an  effort  to  demonstrate  the  i)resence  of  gonococci.  The  methods 
of  conducting  such  examinations,  and  the  periods  at  which  they  are 
most  likely  to  i)e  successful,  have  previously  been  described  in 
Chapter  II.  Unfortunately,  the  acute  stage  during  which  gonococci 
can  usually  be  easily  demonstrated  in  the  discharge  is  also  the  time 
when  a  bacteriologic  examination  is  least  useful,  as  at  this  period  a 
diagnosis  may  generally  be  made  from  tiic  clinical  symptoms  alone, 


194  GONORRHEA    IN    WOMEN 

whereas  in  the  latter  stage,  when  the  disease  lias  become  chronic,  it  is 
often  extremely  difficult  to  demonstrate  the  presence  of  the  specific 
organism.  When  clinical  symptoms  of  gonorrhea  exist  and  in  the  ab- 
sence of  the  microorganisms  in  the  secretions,  as  instanced  by  negative 
smear  preparations,  the  case  is  best  regarded  as  one  of  gonorrhea,  at 
least  until  a  number  of  bacteriologic  examinations,  conducted  under 
favorable  circumstances,  have  been  performed.  It  is  in  such  cases  as 
these  that  cultures  made  by  a  skilled  bacteriologist  will  be  of  especial 
service. 

Boese  and  Schiller^  consider  that  the  recognition  of  the  gonococci 
in  smear  preparations  is  not  essential  for  the  establishment  of  a  diag- 
nosis of  gonorrhea,  provided  the  clinical  manifestations  of  the  disease 
are  present  in  the  lower  genital  tract. 

After  the  clinical  symptoms  of  gonorrhea  have  subsided,  all 
patients  should  be  subjected  to  repeated — at  least  three — thorough 
bacteriologic  examinations  performed  under  circumstances  favorable 
for  the  detection  of  the  microorganisms  before  they  are  pronounced 
cured;  if  unmarried,  they  should  be  instructed  to  return  for  further 
examination  when  contemplating  matrimony  or  on  the  first  appearance 
of  any  symptoms  suggestive  of  a  recurrence  of  the  original  condition. 
In  married  patients  the  greatest  care  should  be  exercised  to  obtain 
complete  cure  before  marital  relations  are  resumed. 

Method  of  Dealing  with  Female  Gonorrheics. — It  will  here  be 
sufficient  merely  to  allude  to  what  has  been  said  in  Chapter  VII  re- 
garding the  necessity  of  warning  all  gonorrheics  concerning  the  nature 
of  their  disease  and  its  dangers,  both  to  themselves  and  to  others. 
In  this  respect  the  physician's  position  is  often  an  .extremely  difficult 
one,  especially  if  the  patient  is  a  married  woman.  Under  no  circum- 
stances should  the  patient  be  left  in  ignorance  as  to  the  infectious 
nature  of  her  disease.  On  the  other  hand,  care  must  be  taken  not  to 
arouse  suspicion  of  marital  infidelity  in  a  case  that  may  possibly  be 
the  result  of  an  extragenital  infection.  In  this  respect  no  rule  can  be 
laid  down  to  govern  all  cases.  Under  such  circumstances  common 
sense  and  tact  are  the  essentials.  An  endeavor  should  be  made  to 
have  the  husband  consult  a  genito-urinary  surgeon,  as  it  is  obviously, 
futile  to  attempt  to  cure  a  gonorrhea  in  a  woman  whose  husband  is 
afflicted  with  a  neglected  or  chronic  gleet  or  other  form  of  Neisserian 
infection,  and  who  is  constantly  reinfecting  his  wife.  There  is  no 
class  of  cases  in  which  more  tact,  judgment,  and  diplomacy  are  required 
on  the  part  of  the  physician  than  in  the  treatment  of  victims  of  marital 
infection. 

'  Boese  and  Schiller:  Berlin,  klin.  Wochenschr.,  1898,  No.  26,  p.  .580;  No.  27,  p.  600; 
Ao.  28,  p.  62.5;  No.  29,  p.  643;  also  Ann.  de  gynec.  et  d'obst.,  ParLs,  1898,  vol.  1,  p.  226. 


CHAPTER  IX 
GONORRHEA  OF  THE  EXTERNAL  GENITALIA 

GONORRHEAL  VULVITIS 

The  most  frequent  etiologic  factor  in  the  production  of  inflanniia- 
tion  of  the  vulva  is  the  gonococcus.  That  gonorrheal  vulvitis  is  not 
more  often  encountered  among  adults  can  be  explained,  to  a  great 
extent,  by  the  histologic  structure  of  this  region.  The  covering  of 
the  outer  portions  of  the  vulva  is  similar  to  that  of  the  skin,  whereas 
on  the  iinier  surfaces  of  the  labia  the  stratified  squamous  epithelium 
becomes  more  delicate  and  gradually  merges  into  that  of  the  vagina. 
It  is  only  with  difficult}^  that  a  lesion  in  the  skin  can  be  produced  by 
the  application  of  pure  cultures  of  gonococci,  and  were  it  not  for  modi- 
fications resulting  from  local  conditions,  such  as  moisture,  friction, 
and  discharges,  vulvitis  in  the  adult  would  be  even  less  frequent  than 
it  is.  The  comparative  infrequency  of  vulvitis  in  adults  as  compared 
with  children  can  be  explained  on  the  ground  that  in  the  former 
the  protective  epithelium  is  tougher,  better  developed,  and  therefore 
more  resistant  than  in  the  latter.  The  bactericidal  properties  of  the 
vaginal  and  cervical  secretions  with  which  the  vulva  is  more  or  less 
constantly  bathed  also  tend  to  lessen  the  dangers  of  infection  in  this 
location.  This  is  particularly  true  of  the  inner  aspects  of  the  vulva, 
whereas  the  outer  surfaces  possess  more  definitely  the  histologic  pro- 
tective properties  previously  mentioned.  (Jonorrheal  vulvitis  in 
adults  is  nearly  always  secondary  to  gonorrhea  in  other  portions  of 
the  genital  tract,  and  usually  results  from  tlie  irritating  discharge 
thus  produced. 

Symptoms.  -In  general  these  are  similar  to  those  symptoms  ac- 
c()in));iiiyiMg  dermatitis  in  other  locations,  but  are  somewhat  UKxli- 
tied  as  a  result  of  local  conditions.  liartholinilis,  urethritis,  and 
cervicitis  are  usually  present.  The  severity  of  the  symptoms  varies 
according  to  tlie  individual  case.  The  onset  is  usually  insidious,  but 
may  l)e  abrupt.  The  vulva,  and  especially  the  fourchet,  are  red, 
swollen,  and  lender,  and  marked  edema  may  be  ijrcsnit.  The  re- 
sulting discharge  may  be  tliin  and  milky  at  lirst,  l)ut  in  a  few  daj's, 
if  treatment  is  not  instituted,  it  becomes  profuse  and  purulent.  Gono- 
cocci are  present  in  the  exudate.     The  tissues  arc  inten.sely  congested, 

I'.C) 


196  GONORRHEA    IN    WOMEN 

and  in  some  cases  the  affected  areas  are  partially  covered  with  a  pseudo- 
diphtheric  membrane,  beneath  which  ulcers  may  form.  These  ulcers 
are  tender  and  bleed  readily.  The  entire  surface  of  the  vulva  is  often 
bathed  in  pus,  which  also  collects  in  the  fossa  navicularis.  The  carun- 
cul«  myrtiformes  or,  in  the  case  of  virgins,  the  hymen,  is  reddened, 
swollen,  and  tender.  Occasionally  infection  of  the  hair-follicles  or 
of  the  sebaceous  or  sweat-glands  occurs,  and  when  this  takes  place, 
numerous  small  pustules  are  present.  In  neglected  cases,  as  a  result 
of  uncleanliness,  crusts  may  form  about  the  external  genitalia,  and 
beneath  these  superficial  ulcers  and  cracks  or  fissures  may  be  present. 
In  untreated  cases  the  discharge  usually  gives  rise  to  eczematous  skin 
lesions  on  the  surrounding  parts.  Condylomata  acuminata  and 
inguinal  adenitis  may  accompanj^  the  condition.  The  latter  is 
usually  bilateral,  although  not  infrequently  one  side  is  more  severely 
or  extensively  involved  than  the  other.  The  subjective  symptoms 
necessarily  vary  with  the  gravity  of  the  lesions  present.  In  mild 
cases  these  may  consist  only  of  slight  itching  or  chafing  about  the 
external  genitalia,  whereas  in  the  presence  of  severe  lesions  the  pain 
may  be  intense.  As  a  result  of  the  passage  of  urine  over  the  inflamed 
areas,  the  symptoms  are  usually  aggravated  by  micturition.  Walking 
or  friction  also  tends  to  increase  the  subjective  symptoms,  whereas 
rest  in  the  recumbent  position  will  allay  the  discomfort.  When  the 
condition  is  very  acute  and  febrile,  constitutional  symptoms  may 
appear,  and  these  are  especially  likely  to  be  manifested  if  an  inguinal 
adenitis  accompany  the  vulvitis.  A  neglected  vulvitis  of  gonorrheal 
origin  tends  to  run  a  chronic  course  and  to  spread  to  other  portions 
of  the  genital  tract.  The  diagnosis  of  gonorrheal  vulvitis  should 
always  be  confirmed  by  a  bacteriologic  demonstration  of  the  specific 
organism  in  the  exudate. 

Treatment. — An  examination  should  always  be  made  to  ascertain 
if  the  disease  is  secondary  to  a  lesion  in  the  upper  genital  tract;  if  this 
is  the  case,  arrest  of  the  irritating  discharge  is  of  the  first  import- 
ance. In  making  the  examination  to  determine  this  point,  care  must 
be  exercised  to  avoid  introducing  infectious  material  into  the  vagina 
from  the  external  genitalia.  (For  the  technic  of  examination  see 
p.  188.)  If  the  patient  is  found  to  be  sufTering  from  a  cervi- 
citis, a  vaginal  douche  consisting  of  a  gallon  of  bichlorid  solution 
1 :  5000  should  be  given  twice  daily,  after  which  a  suitable  tampon 
should  be  introduced.  This  treatment  is  indicated  not  only  for  the 
cure  of  the  primary  lesion,  but  also  to  check  the  discharge,  which  in 
such  cases  is  the  exciting  factor  in  the  vulvitis.  Cleanliness  is  an 
essential  feature  in  the  treatment  of  vulvitis.     This  is  best  effected 


i 


GONORRHEA  OF  THE  EXTERNAL  GENITALIA  197 

by  shaving  or  cropping  the  hair  of  the  external  genitaha  and  by 
frequent  douching  of  the  inflamed  areas  with  weak  antiseptic  solu- 
tions, such  as  bichlorid  1 :  8000,  phenol  1 :  20  or  1 :  40,  or  5  per  cent. 
antipjTin.  In  the  author's  hands  the  last-named  drug  has  given 
excellent  results,  not  only  because  of  its  curative  action,  but  especially 
for  its  antipsoric  properties.  Perrin'  recommends  irrigating  the  in- 
flamed areas  with  a  solution  of  sterile  yeast,  and  reports  that  he  has 
had  excellent  results  from  this  treatment.  The  solution  should  be 
employed  sufficiently  often  to  keep  the  vulva  free  from  discharge. 
This  treatment  is  best  applied  bj^  gently  separating  the  labia  and  pour- 
ing the  warmed  solution  over  the  affected  parts.  If  this  procedure 
does  not  entirely  remove  all  the  exudate,  the  vulva  may  be  carefully 
wiped  with  [iledgets  of  cotton  soaked  in  one  of  the  following  solutions: 
25  per  cent,  argyrol,  12  per  cent,  protargol,  or  a  3  to  6  per  cent,  silver 
nitrate.  Webster-  recommends  a  solution  consisting  of  from  10  to  25 
drops  of  formalin,  6  ounces  of  glj'cerin,  and  14  ounces  of  water.  The 
strength  and  choice  of  the  solution  should  be  governed  by  the  severity 
of  the  attack.  A  strip  of  gauze  or  absorbent  cotton  moistened  in  the 
solution  may  then  be  placed  between  the  labia,  and  a  soft,  sterile 
vaginal  dressing  applied.  If  the  condition  is  a  very  acute  one,  and 
is  accompanied  by  severe  pain,  the  application  of  warm  lead-water 
and  laudamim  may  be  employed  continuously.  Hot  sitz-baths  con- 
taining sodium  bicarbonate  are  also  valuable.  During  the  acute 
stage  patients  should  be  confined  to  bed.  After  the  discharge  has 
begun  to  subside,  itching  may  become  a  pronounced  symptom.  This 
can  usually  be  relieved  by  the  use  of  a  5  per  cent,  antipyrin  spray  or 
the  application  of  a  dusting-powder,  such  as  boric  acid  and  acetanilid, 
equal  parts  of  each,  bismuth  subnitrate,  or  zinc  oxid.  Anspach'* 
recommends  the  addition  of  1  per  cent,  powdered  burnt  alum  to  the 
lead-water  and  laudanum.  In  the  chronic  stage,  if  small  ulcers  are 
present,  their  resolution  may  be  hastened  by  the  apj^lication  of  silver 
nitrate  in  the  form  of  the  solid  stick.  After  each  defecation  or  urina- 
tion the  external  genitalia  shcnild  be  carefully  cleanscnl  with  a  weak 
antiseptic  solution.  Rectal  examinations,  the  administration  of  enc- 
niata,  and  the  introduction  of  sui)i)()sitories  are  counteiindicated  in 
these  and  in  all  other  cases  of  gonorrhea  in  which  the  possibility  of 
introducing  infectious  material  into  the  rectum  exists.  Tiiis  ]ire- 
caution  should  be  especially  ob.served  in  those  cases  in  which  tlic 
<lischarge  is  profuse  and  is  caused  by  an  acute  condition. 

'  I'l-mii:    Kcv.  .\Iril.  lie  la  Suisse  Kom.,  l!)l  1,  vol.  xxxi,  p.  7:52. 

'  Wclislcr;    DLsoiiscs  of  \Voiii(!ii,  Pliilaiiclplii:!  iiml  I.oiiiloii,  lil07. 

'  Ansparli:   ( lyni-coloKy  and  .\l)iloniiiial  Siirfjcry,  Krily  ami  NoMr,  vol.  i,  liM)7. 


198  GONORRHEA    IN    WOMEN 

As  in  all  cases  of  gonorrhea  of  the  lower  genital  tract,  all  soiled 
dressings  should  be  burned,  the  patient  warned  of  the  infectious 
character  of  the  disease,  and  every  prophylactic  measure  possible 
employed  to  prevent  the  spread  of  the  infection.  Especial  care  should 
be  taken  to  avoid  carrying  the  infection  to  the  eye,  thus  preventing 
the  development  of  ophthalmia.  Coitus  should  be  interdicted,  and 
in  chronic  cases,  where  this  cannot  be  prevented,  precautionary 
measures  should  be  adopted.  When  underclothing  has  been  con- 
taminated bj'  gonococcus-bearing  albuminous  discharges,  it  is  better 
first  to  place  the  garments  in  some  disinfectant  solution  that  does  not 
coagulate  albumin.  If  they  are  at  once  put  in  the  steam  sterilizer, 
the  albumin  in  the  discharge  becomes  coagulated  and  results  in  the 
production  of  unsightly  stains. 

CONDYLOMATA  ACUMINATA 

Condylomata  acuminata,  verruca  acuminata,  or  venereal  warts, 
are  a  frequent  accompaniment  of  vulvitis,  and  are  found  most  often 
among  the  uncleanly.  They  are  particularly  likely  to  appear  if 
pregnancy  should  take  place.  These  tumors  occur  more  frequently 
and  attain  greater  dimensions  in  women  than  in  men,  owing  to  the 
fact  that  in  the  former  the  gonorrheal  discharges  are  constantly 
brought  in  contact  with  the  vulva,  perineum,  and  adjacent  skin  sur- 
faces. The  tumors  may  surround  the  anus,  and  on  separating  them, 
a  fistula  in  ano  is  not  infrequently  found.  Children  are  by  no  means 
immune,  and  infants  and  young  girls  suffering  from  vulvovaginitis 
are  frequently  attacked.  Smith'  has  reported  the  occurrence  of 
venereal  warts  of  gonorrheal  origin  in  an  infant  nineteen  months  old. 

The  vegetations  vary  in  size  from  extremely  small  growths  to 
tumors  the  size  of  a  man's  fist.  They  may  occur  as  discrete  excres- 
cences, or  they  may  coalesce,  forming  large,  cauliflower-like  neoplasms. 
The  confluent  tumors  usually  originate  from  a  broad  sessile  base, 
whereas  the  discrete  warts  are  not  infrequently  pedunculated.  These 
outgrowths,  except  when  they  are  modified  by  local  conditions,  are 
similar  in  color  to  the  surrounding  skin.  Not  infrequently,  as  a  result 
of  being  continuously  bathed  in  an  irritating  discharge,  the  warts 
become  reddened  or  purplish  in  color  and  very  vascular.  Their 
surfaces  may  be  macerated.  They  may  be  present  on  the  vulva  or 
contiguous  skin  surface,  or,  more  rarely,  may  extend  into  the  vagina. 
The  symptoms  arising  from  the  presence  of  condylomata  acuminata 
are  similar  to  those  of  chronic  vulvitis.  The  exudate  is  usually  sanious, 
offensive,  and  highly  irritating.  The  more  vascular  the  warts  and  the 
thinner  their  epithelial  covering,  the  more  profuse  is  the  discharge. 

'  Siiiitli,  K.  R.:   Amer.  Gynecology,  December,  1903. 


Fig.  28.— Condyloj 

Sliowing  a  ruse  of  moderately  cxtei 

iibfjiit  the  amis  and  on  the  perineum,  wh 

of  numerous  small  growths,  are  present. 


ATA    A(  I'MtNATA    OF    TUK    F^XTEHNAL    GkNITAI.IA. 

*ivc  venereal  warts.  A  number  of  discrete  oulKiowtlis  may  be  seen 
,e  on  each  side  of  the  vulva  oblong  tumors,  formed  by  the  eoalescence 
The  tumors  ou  the  skin  show  clearly  the  pointed  character  of  these 


ncopla.'fms.  On  the  inner  side  of  the  right  labium  minus  are  two  flattened,  softened  tumors,  their  condition 
being  due  to  the  l()cation  they  occupy.  In  this  case  the  vulvar  outlet  was  bathed  in  a  purulent  discharge,  and 
I  lie  riiueosa  at  rln-  external  urinary  meatus  was  reddened,  thickened,  and  somewhat  everted. 


GONORRHEA  OF  THE  EXTERNAL  GENITALIA  199 

The  diagnosis  is,  as  a  rule,  not  difficult.  The  possibility,  however, 
of  syphilis  being  the  etiologic  factor  should  ahvaj's  be  considered 
liefore  treatment  is  instituted.  In  general,  gonorrheal  vegetations 
may  be  distinguished  from  syphilitic  condylomata  by  their  smaller 
size  and  pointed  appearance,  the  growths  due  to  specific  disease  being, 
as  a  rule,  fiat  and  broad.  In  neglected  cases  too  much  weight  should 
not  be  placed  upon  the  appearance  of  the  growth,  but  other  symptoms 
and  evidences  of  syphilis  should  be  looked  for.  It  should  also  be 
remembered  in  this  connection  that  both  diseases  may  coexist. 

(-'ondylomata  acuminata  probably  are  largely  toxic  in  origin.  The 
author  has  never  been  able  to  demonstrate  the  presence  of  gonococci 
in  these  tumors,  although  repeated  efforts  have  been  made.  The 
organisms  are  frequently  found  upon  the  surface  and  in  the  crypts 
of  the  tumors.  Similar  results  have  been  obtained  by  a  number  of 
other  investigators.  Streptococci  and  staphylococci  have,  however, 
l)con  observed. 

Treatment. — This  consists  in  cleansing  the  affected  area  with  weak 
antiseptic  solutions,  and  checking  the  discharge,  as  described  imder 
the  treatment  of  vulvitis.  After  the  application  of  the  antiseptic 
solution  the  warts  should  be  dried  with  cotton,  dusted  with  a  non- 
irritating  antiseptic  powder,  and  a  sterile  dressing  applied.  This 
t  i-eatment  should  be  repeated  sufficiently  often  to  keep  the  lesions  dry. 
Motion  should,  so  far  as  possible,  be  restricted.  Although  mild  cases 
may  respond  to  this  treatment,  as  a  rule  more  active  measures  are 
necessary.  It  is  often  difficult  thoroughly  to  carry  out  this  treatment  in 
the  class  of  patients  among  whom  venereal  warts  are  most  prevalent. 
Even  under  the  most  favorable  circumstances  the  palliative  treatment 
is  slow  and  tedious,  and  if  the  veg(>tations  are  of  medium  or  large  size, 
the  method  should  be  employed  only  as  a  preliminary  to  operative 
intervention.  The  type  of  operation  selected  will  naturally  vary  with 
the  size  and  shape  of  the  tumors.  If  the  warts  are  few  in  number, 
and  especially  if  they  are  pedunculated,  they  may  be  snipped  off  with 
a  i)air  of  sharp  scissors  curved  on  the  flat,  and  the  base  of  the  growths 
touched  with  fuming  nitric  acid.  Before  this  is  done,  the  surrounding 
skin  surfaces  should  be  protected  with  vasclin  or  other  greas\'  sul)- 
stance.  Care  should  be  taken  to  remove  as  little  healthj'  tissue  as 
possible,  for  fear  of  opening  avenues  of  infection.  If  only  one  or  two 
tumors  arc  to  be  excised,  the  operation  can  be  performed  under  local 
anesthesia,  a  weak  cocain  solution  or  Schleich's  fluid  being  injected  into 
the  base  of  the  warts,  or  they  may  simply  be  cut  off  without  employing 
any  anesthetic  whatever.  An  excellent  local  anesthetic  that  has 
gi\('n  good  rcs\ilts  in  these  cases  is  ethyl  chlorid.     Sclicin'  lias  rcccnlly 

'Scliiin:    Wicn.  kliii.  Wocliciisclir.,  vol.  xviii,  \u.  ."). 


200  GONORRHEA    IN    WOMEN 

reported  the  successful  treatment  of  30  cases  of  venereal  warts  by 
the  use  of  ethyl  chloric!  alone;  he  freezes  the  base  of  the  tumor  and 
the  tumor  itself.  This  treatment  effects  obliteration  of  the  blood- 
vessels by  stasis  and  thrombosis,  and  in  a  few  days  the  tumors  dry 
up  and  drop  olT.  If  necessary,  the  treatment  may  be  repeated  at 
three-day  intervals.  The  speed  with  which  the  cure  is  effected  by 
the  Schein  method  depends  largely  upon  the  type  of  tumor.  The 
advantages  of  the  ethyl  chloric!  treatment  are  that  it  is  bloodless, 
requires  no  preliminary  preparation,  is  nearly  painless,  and  is  applica- 
ble to  all  cases.  In  the  author's  experience,  to  be  effective  the  freezing 
must  be  continued  for  four  or  five  minutes  for  each  tumor.  This  plan 
of  treatment  can  often,  with  advantage,  be  combined  with  excision. 
In  operations  performed  imder  local  anesthesia,  when  the  growths  are 
numerous,  it  is  best  to  divide  the  treatment  into  two  or  more  sittings. 
In  many  cases  in  which  the  vegetations  are  extensive  it  is  preferable  to 
employ  a  general  anesthetic  and  excise  all  the  growths  at  one  opera- 
tion. If  this  method  is  decided  upon,  the  patient  should  receive  pre- 
liminary treatment  for  a  few  days  or  a  week  prior  to  the  operation, 
with  the  view  to  sterilizing,  as  far  as  possible,  the  diseased  area  and 
arresting  the  discharge.  Prior  to  the  operation  the  parts  may  be 
painted  with  a  5  per  cent,  iodin  solution.  The  pedunculated  tumors 
are  best  removed  with  a  cautery  knife  heated  to  a  dull  red.  Those 
neoplasms  that  spring  from  a  broad  base  can  be  most  satisfactorih^ 
excised  with  the  knife,  every  effort  being  made  to  avoid  infection  of 
the  wound  both  during  and  after  the  operation.  When  the  excision 
is  completed,  the  wound  may  be  closed  by  interrupted  silkworm-gut 
sutures. 

Watson^  reports  excellent  results  from  the  use  of  lactic  acid  in  the 
treatment  of  these  cases.  Large  masses  are  isolated  and  kept  sur- 
rounded by  strips  of  lint  moistened  in  a  0.5  or  1  per  cent,  lactic  acid 
solution,  and  the  base  of  the  tumors  touched  at  intervals  with  the 
pure  acid.  Small  growi;hs  are  painted  with  a  strong  solution  or  with 
the  pure  acid.  When  the  field  is  large,  the  minute  vegetations  are 
covered  with  a  wet  dressing.  These  dressings  are  frequently  changed, 
and  after  each  change  a  sitz-bath  is  administered.  Watson  states 
that  small  masses  drop  off,  that  the  growth  of  large  vegetations  is 
inhibited,  and  that  a  cure  results  without  leaving  cicatrices  and 
without  accompanying  pain.  Occasionally,  if  the  treatment  is  pushed 
too  energetically,  an  erythema  is  produced.  This  is  mild  in  nature 
and  subsides  rapidly  on  withdrawal  of  the  acid.  On  this  account,  if 
large  areas  are  involved,  the  healthy  skin  should  be  protected  by 
'  Watson,  D.:  Lancet,  London,  April  13,  1912,  p.  990. 


GONORRHEA    OF    THE    EXTERNAL   GENITALIA  201 

vaselin  and  the  acid  entirely  omitted  for  two  daj's  out  of  every  week. 
Tlie  time  required  for  cure  by  this  treatment  depends  upon  the  in- 
dividual case  and  the  extent  of  the  growth.  One  case  was  completely 
cured  in  twelve  days,  another  in  seventeen  days,  and  an  extensive 
growth  disappeared  in  seven  weeks.  If  the  discharge  is  not  checked 
and  all  the  vegetations  removed,  the  disease  tends  to  recur.  Prophy- 
lactic measures,  such  as  are  recommended  in  the  treatment  of  vulvitis, 
should  be  instituted. 

In  severe  cases  the  tumor  masses  may  almost  entirely  cover  the 
anus,  perineum,  and  vulva.  Under  such  circumstances  the  frequent 
wetting  of  the  growth  with  urine  and  the  contamination  with  fecal 
material  add  greatly  to  the  discomfort  of  the  patient  and  the  difficulty 
of  care.  The  most  extensive  growths  are  often  seen  in  pregnant 
women,  and  the  problem  presented  to  the  obstetrician  under  such 
circumstances  is  frequently  a  difficult  one,  as  even  with  the  greatest 
care  and  cleanUness  the  risk  of  infection  at  the  subsequent  labor  is 
very  considerable,  especially  if  operative  delivery  becomes  necessary. 
Naturally,  the  obstetrician  must  be  guided  by  the  individual  case. 
Some  authorities  recommend  excision  of  the  tumors.  This  is  the  course 
adopted  by  Markoe'  in  the  case  of  large  condylomatous  masses  sur- 
rounding the  vulva.  Such  operations  freciuently  precipitate  labor 
and  should,  therefore,  not  be  undertaken  until  near  term.  Checking 
of  the  vaginal  discharge  and  cleanliness  are  the  sheet-anchors  in  the 
treatment  of  condylomata  acuminata  of  gonorrheal  origin,  and,  when- 
ever possible,  should  always  constitute  the  preliminary  treatment  to 
oiK>ration.  The  a])plicati()n  of  the  a:-ray  seems  to  produce  a  marked 
inhibitory  action  on  the  growth  of  these  tumors,  and  if  persisted  in,  is 
said  to  produce  a  cure  in  many  cases.  Dubreuilh-  has  had  excellent 
results  with  this  form  of  treatment.  The  use  of  the  .r-ray  is  contra- 
indicated  during  pregnancy  because  of  the  danger  to  the  fetus. 

BARTHOLINITIS 
The  glands  of  Bartholin  derive  their  name  from  Bartholinus. 
These  structures  were  studied  by  Huguier'  in  185(5,  and  were  termed 
by  him  the  vulvovaginal  glands.  The  glands  are  situated  in  the 
lower  and  posterior  portion  of  the  labia  majora,  partly  under  the 
bulbocavernosus  (sphincter  vagina^)  muscle.  In  some  subjects  they 
are  entirely  covered  by  this  muscle,  whereas  in  others  they  are  par- 
tially ('iiiiicddcd  in  the  spongy  tissue  of  tlic  hiillis.     The  glands  extend 

Markoc,  ,1.  \V.:   Hull.  I,yiiiK-in  llospiliil.  New  York,  .liino,  MM-',  vol.  viii,  No. :{,  p.  1 1.}. 

Dulirciiilh,  \V.:  .lour.  <lc  M('.l.  <|..  Hor.loiiiix,  AuRihst  11,  1!)12. 

lluKuiiT:    .Mriiioins  ,U-  V \r:v\<'-unc  ,U-  .Mc'dr.-iiw,  l':in.s  lS,-,(i,  vol.  XV,  p.  XU  . 


202  GOXORRHEA    IN    WOMEX 

posteriorly  to  the  triangular  ligament.  Normallj',  they  are  about 
the  size  of  a  small  bean,  but  vary  quite  markedly  even  in  health,  and 
as  a  result  of  inflammation  they  often  become  much  enlarged.  The 
ducts  of  the  glands  empty  on  the  inner  surface  of  the  labia  minora, 
just  in  front  of  the  hymenal  insertion.  The  glands  are  composed  of 
numerous  divisions.  The  infection,  first  of  one  branch  and  then  of 
another,  accounts  for  the  recurrence  of  suppuration  on  the  same  side. 
The  function  of  Bartholin's  glands  is  to  lubricate  the  introitus.  The 
glands  are  the  frequent  lurking-place  of  the  gonococci.  The  frequency 
with  which  the  vulvovaginal  gland  is  infected  in  cases  of  gonorrhea  is 
equaled  only  in  two  other  localities,  namely,  the  urethra  and  the  cervix. 
According  to  Luczny,i  statistics  collected  from  Olshausen's  clinic  show 
that  this  location  is  infected  in  36  per  cent,  of  all  cases.  Finger-  found 
them  infected  in  about  50  per  cent,  of  his  cases.  Menge,^  combining 
the  statistics  of  Bumm,  Steinschneider,  Fabry,  Briinschke,  Brose, 
and  Welander,  found  Bartholin's  glands  infected  in  20  per  cent,  of 
both  chronic  and  acute  cases. 

The  frequency  of  bartholinitis  is  dependent  upon  a  number  of 
factors — the  location  of  the  gland  opening,  which  naturally  makes  it 
peculiarly  likely  to  infection  during  coitus;  the  activity  of  the  gland 
during  sexual  excitation;  it  seems  fair  to  assume  that  during  the 
process  of  lubrication  of  the  introitus  the  opening  of  the  duct  of  the 
gland  widens  somewhat;  the  location  of  the  duct  opening,  which 
facilitates  secondary  infection  by  gonococci-bearing  cervical  or  ure- 
thral discharges;  and,  lastly,  the  histologic  structure  of  the  gland  and 
the  chemical  reaction  of  its  secretion,  which  favor  the  growth  of  the 
gonococcus. 

When  \ulvitis  is  present,  the  glands  are  nearly  always  infected, 
whereas,  on  the  other  hand,  a  bartholinitis  is  frequently  present 
without  an  accompanying  vulvitis.  As  has  been  stated,  this  is  one 
of  the  localities  in  which  gonococci  are  most  prone  to  persist.  In 
many  cases  a  vulvitis  and  bartholinitis  have  both  been  present  during 
the  acute  stage  of  the  disfease,  but  the  infection  of  the  vulva  has  either 
subsided  or  yielded  to  treatment,  while  that  of  the  gland  has  con- 
tinued, with  the  result  that  when  the  patient  is  examined  during  the 
chronic  stage  of  the  gonorrhea,  the  vulva  appears  normal,  while  the 
glandular  involvement  still  continues  and  is  more  or  less  pronounced. 

Bartholinitis  has  been  observed  as  early  as  two  weeks  after  the 
c)i-iginal  infection,  but  may  occur  at  any  time  during  the  course  of  a 

'  Luczny:  Quoted  by  Clark:  New  York  Med.  Jour.,  March  3,  1900. 

=  Finger:   Wien.  klin.  VVochenschr.,  1897,  No.  3. 

'  Menge,  K.:   Handbuch  der  Clcschlcchtskraiiklipiten.  Mcnua,  1910. 


GONORRHEA    OF    THE    EXTERNAL   GENITALIA  203 

gonorrhea — most  frequently  during  the  first  year  of  the  disease. 
Barthohnitis  may  inckide  varying  degrees  of  infection  of  either  the 
duct  alone  or  of  the  duct  and  the  gland. 

CYST  OF  BARTHOLIN'S  GLAND 

If  the  infection  is  of  a  mild  type  and  confined  to  the  duct,  occlusion 
of  the  latter  may  take  place.  The  resulting  cyst  forms  slowly,  is 
ovoid  in  shape,  and  tends  to  bulge  into  the  introitus.  If  pregnancy 
takes  place,  the  growth  of  the  cysts  is  usually  more  rapid.  As  the 
swelling  increases  the  vaginal  cleft  becomes  distorted.  The  surface 
of  the  tumor  is  smooth,  and  the  gland  exit  is  reddened  and  prominent. 
Only  rareh'  will  these  tumors  show  transmitted  light.  The  cysts  vary 
in  size  from  that  of  a  pea  to  that  of  a  goose-egg.  Wiener'  reports  the 
history  of  an  unusual  case,  in  which  the  cysts  were  bilateral  and 
measured  respectively  11  by  8  cm.  and  12  by  5  cm. 

The  cyst  contents  are  viscid,  colorless  or  yellow,  or  may  be  choco- 
late color,  owing  to  an  admixture  of  blood.  They  are  usually  uni- 
locular and  unilateral,  and  are  said  to  be  found  more  frequently  on  the 
left  than  on  the  right  side.  They  may  occur  at  any  time  after  puberty, 
and  in  rare  instances  develop  at  an  earlier  age.  The  cysts  are  usually 
painless,  but,  owing  to  their  size,  they  may  cause  inconvenience  during 
walking  or  coitus.  Bilateral  cy.sts  are  more  prone  to  produce  dis- 
comfort on  movement  than  are  the  unilateral  tumors.  Not  infre- 
(luently  the  smaller  cysts  are  discovered  only  accidentally,  perhaps 
(luring  the  course  of  a  gynecologic  examination  instituted  for  some 
other  mf)re  important  lesion.  Indeed,  in  this  way  not  infrequently 
small  cysts  are  found  the  jirescnce  of  which  has  not  been  known  to 
the  patient. 

Because  of  extension  of  the  infection  or  as  the  result  of  trauma 
the  cysts  may  suppurate  and  an  abscess  result.  These  cysts  are  to 
l)e  differentiated  frf)m  hernia,  hydrocele  of  the  round  ligament,  vaginal 
cysts,  solid  tumors  of  (he  labium,  perirectal  abscese,  and  from  hernia 
and  cyst  combined. 

Treatment,  'i'liis  consists  of  excision  of  the  cyst,  gland,  and  duct. 
l'"or  this  purpose  a  vertical  incision  is  made  on  the  iiuier  surface  of 
the  labia,  over  the  tumor,  antl  the  entire  cyst  is  dissected  out.  Care 
should  be  taken  to  avoid  "l)uttonholing"  the  vaginal  mucous  mem- 
l)rane.  In  some  cases  the  deej)  dissection  may  be  facilitated  by  intro- 
iliicing  a  gloved  finger  into  the  rectum,  pushing  the  tumor  forward. 
Hut  this  procedure  is  to  be  avoided,  if  possible,  owing  to  the  increased 
daniicr  iif  iiilcct  ion.  If.  during  tlie  course  (if  the  cystectoniy.  the 
'  \\  iriiLT,  S.:  .Viiicr.  .loui-.  (JlhstL'i.,  IVhniar.v,  lull',  p.  'Ji'.i. 


204  GONORRHEA    IN    AVOMEN 

cyst  is  ruptured,  its  removal  will  be  facilitated  by  packing  the  cavity 
with  a  narrow  strip  of  sterile  gauze,  as  recommended  by  Schoenberg.' 
This  distends  the  cyst  cavity  and  facilitates  the  entire  removal  of 
the  latter.  It  is  better,  however,  when  possible,  to  excise  the  tumor 
without  rupturing  it,  as  by  this  procedure  excision  of  the  entire  cyst- 
wall  is  assured.  Some  authorities  have  suggested,  as  a  preliminary 
step  to  the  operation,  the  evacuation  of  the  cyst  contents  and  the 
filling  of  the  cavity  with  paraffin,  for  the  purpose  of  causing  distention. 
As  a  rule,  considerable  bleeding  from  the  depths  of  the  wound  occurs: 
this  can  be  controlled  by  the  introduction  of  a  layer  of  buried  fine 
catgut  sutures.  Care  should  be  taken  to  leave  no  dead  spaces.  Drain- 
age is  not  necessary,  unless  infection  has  occurred,  and  at  the  com- 
pletion of  the  operation  the  skin  may  be  closed  by  a  subcuticular 
suture.  The  wound  should  be  carefully  guarded  against  infection. 
Palliative  treatment,  such  as  evacuation  of  the  cyst  contents  through 
the  duct  and  the  introduction,  through  the  latter,  by  means  of  a  blunt- 
pointed  hypodermic  syringe,  of  formalin  or  a  solution  of  silver  nitrate, 
is  unsatisfactory  and  usually  results  in  recurrence  of  the  cyst.  In 
most  cases  simple  incision  is  followed  by  similar  results. 

ABSCESS  OF  BARTHOLIN'S  GLAND 
Infection  of  the  vulvovaginal  gland  by  the  gonococci  may  give 
rise  to  a  non-suppurative  adenitis.  Indeed,  Halle'-  and  other  writers 
assert  that  an  abscess  is  always  the  result  of  a  mixed  infection.  Cul- 
tures from  the  pus  of  these  abscesses  usually  show  the  presence 
of  the  colon  bacillus,  Staphylococcus  albus,  or  other  pyogenic  micro- 
organisms, as  well  as  the  gonococcus.  Infection  of  the  duct  or 
gland  may  be  present  without  producing  any  palpable  enlargement 
of  either  structure.  The  abscesses  of  the  gland  vary  in  size  from 
one  a  few  centimeters  in  diameter  to  one  the  size  of  a  lemon,  or  in 
rare  instances  even  larger.  They  are  frequently  pyriform  in  shape, 
the  large  end  being  directed  toward  the  rectum.  They  occur  as  an 
accompaniment  to  a  vulvitis,  or  may  arise  independently  years  after- 
ward in  patients  who  have  never  suffered  from  inflammation  of  the 
vulva.  The  abscess  may  be  unilateral  or  bilateral,  and  tend  to  rup- 
ture spontaneously  on  the  inner  surface  of  the  labia,  just  above  the 
exit  of  the  duct.  In  exceptional  cases  the  pus  may  burrow  through 
the  capsule  of  Bartholin's  gland  and  the  abscess  point  on  the  perineum 
or  even  in  the  rectum.  In  this  manner  fistulas  may  develop.  Owing 
to   the  histologic  structure  of   the   gland   the   abscesses   are    likely 

•  Schoenbeig:  Surg.,  Gyn.,  and  Obstet.,  1910,  vol.  x,  p.  .309. 

=  Halle:   "  La  Bactpriologic  du  Canal  gi'nital  de  la  Feinmo,"  The^e  dc  Paris,  1899. 


GONORRHEA  OF  THE  EXTERNAL  GENITALIA  205 

to  recur,  as  many  as  from  twelve  to  fifteen  manifesting  themselves  in 
a  single  individual  in  the  course  of  a  few  years.  The  abscesses  present 
the  usual  appearance  of  a  suppurative  adenitis.  The  local  symptoms 
are  often  quite  severe.  The  affected  area  is  red,  swollen,  and  ede- 
matous, and  the  patient  complains  of  pain  and  tenderness,  which 
are  rendered  worse  by  friction  or  walking,  and  are  partially  relie^•ed 
by  rest  in  the  recumbent  position,  often  with  the  thighs  somewhat 
separated. 

jVIild  constitutional  symptoms  are  not  infrequent.  Inguinal 
adenitis  may  accompany  the  condition.  In  cases  of  old  infection  the 
glands  may  be  palpable  as  hard,  indurated  bodies — the  "adenitis 
glandulae  Bartholinse  scleroticans "  of  Sanger. 

Treatment. — Before  suppuration  has  taken  place  rest  and  the 
application  of  hot  fomentations  maj^  in  some  cases,  abort  the  acute 
attack.  If  success  does  not  quickly  follow  this  treatment,  or  if  pus 
is  formed,  the  abscess  and  duct  should  be  excised  immediately,  a 
similar  technic  being  employed  to  that  described  for  the  treatment  of 
a  cyst  of  the  vulvovaginal  gland.  Every  effort  should  be  made  to 
avoid  rupture  of  the  abscess.  If  this  occurs,  however,  the  abscess 
cavity  should  be  cauterized  with  fuming  nitric  acid,  pure  phenol,  or 
tincture  of  iodin.  A  small  gauze  drain  should  be  inserted  into  the 
lower  angle  of  the  wound,  and  the  upper  three-fourths  of  the  incision 
closed  with  interrupted  silkworm-gut  sutures.  In  performing  the 
operation  it  is  of  the  utmost  importance  that  all  the  glandular  struc- 
ture be  removed  in  order  to  prevent  a  recurrence  of  the  condition.  If 
the  abscess  has  already  ruptured,  the  cavity  should  be  packed  tightly 
with  gauze  soaked  in  pure  formalin  before  the  operation  is  begun. 
Simple  incision,  cauterization,  and  drainage  rarely  effect  a  per- 
manent cure.  In  chronic  cases  the  diseased  gland  should  be  en- 
tirclv  rcmoN'cd  l)v  careful  dissection. 


URETHRITIS 
The  urethra  is  the  portion  of  the  genital  tract  most  frequently 
primarily  infected  by  the  gonococcus.  Welander'  states  that  gono- 
cocci  were  recovered  from  this  canal  in  SO  per  cent,  of  his  cases. 
Hriinschke-  places  the  frefjuency  at  90  per  cent.;  Fabry,''  at  52  per 
cent.;    Steinschneider, '   at    '.)!    per    cent.;    Finger,''  at   75   to  !M)  per 

'  Wolaiiiicr:   (Quoted  liy  Clark;   New  Vcirk  Mc<l.  Jour.,  M:ircli  8,  KlOli. 

'  Hriinschkc:   (^uotcil  Ijy  Stf|)hon.s()n,  S.:  Oplitlmlmia  Ncoiiatoriuii,  Loiiclori.  liHIT,  p.  SI. 

'  Kiihry:   iJcutscli.  iiicd.  Wofhcn.sohr.,  ISfvS,  p.  -13. 

•  .St<'in.schiu-i(liT:    Merlin,  klin.  Woehcaschr.,  1SH7,  No.  17. 

'  Fitigi'r:   (Quoted  by  Stcphcnaon,  S.:   Loc.cil. 


206  GONORRHEA    IN    WOMEN 

cent.;  whereas  Luczny'  records  85  per  cent.  Laser,'  in  353  cases 
of  gonorrheal  infection,  found  the  organism  in  the  urethra  111  times. 
In  80  per  cent,  of  these  111  cases  there  was  no  macroscopic  evidence 
of  a  urethritis.  Schultz'  found  gonococci  in  the  urethra  78  times, 
and  in  the  cervix,  81  times,  in  a  series  of  104  cases.  Dannreuther^ 
believes  that  the  cervix  is  affected  three  times  as  often  as  the  ure- 
thra. Pryor,^  among  197  cases  of  gonorrhea  in  immoral  women, 
found  the  urethra  involved  in  90  per  cent.  Menge,'^  combining 
the  statistics  of  Bumm,  Steinschneider,  Fabry,  Briinschke,  Brose, 
and  Welander,  found  the  urethra  involved  in  95  per  cent,  of  acute  cases 
and  in  30  per  cent,  of  chronic  cases.  Menge's  statistics  agree  closely 
with  the  author's  findings.  Hunner"  is  of  the  opinion  that  urethritis 
is  usually  secondary  to  a  fresh  gonorrheal  inflammation  of  the  vagina 
or  cervix.  There  is  no  doubt  but  that,  in  the  great  majority  of  cases 
of  gonorrhea  of  the  female  genital  tract,  the  urethra  is  infected  at  some 
time  during  the  course  of  the  disease.  Whether  the  infection  occurs 
primarily  in  the  urethra  depends  upon  a  number  of  factors.  If  the 
introitus  is  small  or  the  male  organ  disproportionately  large,  or  in  the 
case  of  newly  married  women,  primary  infection  in  this  region  is  likely; 
on  the  other  hand,  a  gaping  vaginal  orifice  will  render  the  existence  of  a 
urethritis  somewhat  less  probable.  If,  however,  infection  takes  place 
primarily  in  the  cervix,  it  is  usually  a  matter  of  only  a  short  time  before 
the  urethra  becomes  contaminated.  Owing  to  the  anatomic  formation 
of  the  urethra,  inflammation  of  this  structure  is,  per  se,  much  less 
severe  than  a  corresponding  infection  in  the  male.  The  female  urethra 
is  about  3.5  cm.  in  length.  The  external  urinary  meatus  has  a  diameter 
of  about  7  mm.  and,  in  the  nuUipara  at  least,  is  usually  protected  by 
two  small,  wing-like  folds  of  mucous  membrane,  the  labia  urethrse;  in 
the  multipara,  however,  it  is  not  uncommon  to  find  the  external 
urinary  meatus  somewhat  enlarged  and  gaping  widely.  When  the 
canal  is  at  rest,  the  mucosa  lies  in  longitudinal  folds,  between  which, 
especially  on  its  vaginal  surface,  there  are  numerous  gland  openings. 
These  correspond  to  Littre's  glands  in  the  male.  They  vary  from 
simple  tubular  structures  to  complex  racemose  glands.  Toward  the 
outer  end  of  the  urethra  the  glands  are  more  numerous  and  complex. 

'  Liiczny:   Quoted  by  Cl.ark:  New  York  Med.  Jour.,  March  3,  190(i. 
-  La.ser:  Amer.  Medicine,  March  17,  1900. 

^  Sehultz:   Quoted  by  Pozzi,  S.:  A  Treatise  on  Gynecology,  ^\'m.  Wood  and  Co.,  New 
York,  1897,  p.  724. 

'  Dannreuther,  W.  T.:   Med.  Record,  New  York,  November  4,  1911,  p.  921. 

»  Pryor,  W.  R.:  .4nier.  Jour.  Obstet.,  189(5,  vol.  xxxiv,  p.  384. 

'^  Menge,  K.:  Handb.  d.  Geschlechtskr.,  Vienna,  1910. 

'  Hunner:  Gynecology  and  Abdominal  Surgery,  Kelly  and  Noble,  vol.  i. 


GONORRHEA  OF  THE  EXTERNAL  GENITALIA  207 

On  the  floor,  just  within  the  external  urinary  meatus,  are  two 
large  gland  openings.  These  were  first  mentioned  by  Skene, ^  and 
later  more  minutely  described  by  SchiiUer,-  who  occasionally  found  a 
third  and  slightly  smaller  gland  lying  in  the  midline  between  Skene's 
glands.  These  glands  extend  upward  along  the  urethra  for  a  distance 
of  from  5  to  16  mm.,  and  end  in  a  culdesac. 

When  the  gonococcus  is  brought  in  contact  with  the  mucous  mem- 
brane of  the  urethra,  it  enters  these  structures  and,  extending  through 
the  cellular  interstices,  rapidly  produces  a  very  positive  chemotaxis. 
As  a  result  of  infection  the  entire  mucosa  of  the  urethra  becomes 
reddened,  thickened,  and  congested.  The  mucous  membrane  at  the 
external  urinary  meatus  becomes  everted  and,  when  the  labia  are 
separated,  presents  as  a  reddened  area.  Skene's  glands  become  in- 
flamed; the  openings  appear  as  minute  yellowish  spots  surrounded  by 
an  elevated,  congested  zone  of  inflammatory  mucosa.  The  discharge  is 
thin  at  first,  but  soon  becomes  thick  and  creamy.  It  is  j'ellowish  in 
color,  and  may  even  be  blood-streaked,  and  at  this  stage  contains  large 
numbers  of  typical  gonococci.  Pressure  over  Skene's  glands  will  usu- 
ally result  in  the  extrusion  of  a  drop  or  two  of  pus  from  the  gland  exits. 

Abscesses  may  form  in  Skene's  or  other  of  the  urethral  glands. 
As  the  majority  of  the  glands  of  the  urethra  open  in  the  floor  of  that 
structure,  these  areas  of  suppuration  have  been  termed  suburethral 
abscesses.  Huguier'  is  generally  quoted  as  having  been  the  first  to 
describe  this  form  of  gonorrhea,  but  Kelly''  has  directed  attention  to 
the  fact  that  these  lesions  were  previously  described  by  Heys,^  to  whom 
credit  for  this  observation  is  due.  The  abscesses  are  generally  single, 
but  may  be  multiple.  Gicerin'"'  has  described  a  rare  condition  in 
which  nuiltiple  follicular  abscesses  have  occurred,  first  one  and  then 
another  follicle  being  involved.  Suburethral  or  para-urethral  ab- 
scesses usually  discharge  their  contents  into  the  urethra,  but  may 
rupture  into  the  vagina  and  produce  urethro-vaginal  fistulas.  The 
abscesses  are  palpable  as  round  or  ovoid  areas  of  induration  or  fluctua- 
tion, about  1  cm.  in  diameter,  are  extremelj^  tender  to  the  touch,  and 
usually  situated  near  the  external  meatus. 

As  the  inflannnation  subsides  and  the  condition  becomes  more 
chronic,  the  evidences  of  an  acute  lesion  begin  to  disappear.  The 
mucosa  of  the  canal  may  regain  its  normal  .■ip])('ar:iiic(\  although  it 

'  .skciir,  A.  ,1.  ('.:  AiiRT.  .Jimr.  Olisl.,  isso. 

'  SchiiUer:   Frstschiift  f.  Borniird  Schullze,  lierlin,  1883,  vol.  iv,  p.  10. 
'  HuKuier:  M6m.  dc  la  .Soc  do  C'hir.  dc  Paris,  1847. 
'  Kelly,  H.  .\.:  Operative  Gynecology,  1907. 

'  Ileys,  W.:   Praelical  Observations  in  Surgery,  I'liiladelpliia,  ISO."),  p.  :SOI. 
'  Gicerin:  Quoted  by  E.  Finger:   Die  Blennorrlioe  iles  .Scxual-Organs  urid  ilirc  Kimipli- 
kationcn,  Leipzig  anrl  Vienna,  190.3,  p.  300. 


208  GONORRHEA    IN    WOMEN 

usually  presents  evidences  of  inflammation  long  after  all  subjective 
symptoms  of  the  urethritis  have  disappeared.  If,  on  inspection,  the 
orifices  of  Skene's  glands  are  found  to  be  reddened  and  the  surrounding 
mucosa  is  prominent,  this  is  suggestive  of  a  previously  existing  ure- 
thritis. The  anterior  third  of  the  urethra  is  the  location  in  which 
gonorrhea  persists  the  longest.  On  making  pressure  over  Skene's 
glands,  even  in  old  chronic  cases,  it  is  usual  to  obtain  pus  or  a 
little  murky  fluid.  The  fact  that  no  pus  can  be  obtained  from  the 
urethra  is  no  evidence  that  a  complete  cure  has  been  effected.  The 
gonococci  frequently  lie  latent  in  the  urethra,  especially  in  Skene's 
or  Schiiller's  glands,  for  prolonged  periods,  and  may  at  any  time  set 
up  an  acute  condition.  Finger^  states  that  gonococci  not  infrequently 
may  be  found  in  clear  watery  urethral  secretions.  For  purposes  of 
diagnosis  Garceau's-  modification  of  Skene's  female  urethroscope  is 
of  advantage. 

An  attack  of  urethritis  is  ushered  in  by  a  slight  tickling,  itching,  or 
burning  sensation  in  the  urethra  during  and  following  micturition. 
In  a  day  or  two  the  symptoms  become  intensified,  ardor  urinse  in- 
creases, and  the  desire  to  void  urine  becomes  more  marked.  The 
urethritis  may  cause  a  vaginismus.  If  an  abscess  has  formed  in  one 
of  Skene's  glands,  the  local  pain  and  discomfort  becomes  much  more 
severe.  Gradually,  as  the  lesions  become  less  acute,  the  symptoms 
subside.  Occasionally  in  chronic  cases  skenitis,  as  infection  of  Skene's 
glands  is  termed  by  Taussig,^  produces  symptoms  which,  if  a  careful 
examination  is  not  made,  may  lead  to  an  incorrect  diagnosis  of  cystitis. 
The  acute  attack  lasts,  as  a  rule,  from  one  to  three  weeks.  During 
the  chronic  stage,  which  may  continue  for  years,  subjective  symptoms 
are  not  infrequently  entirely  absent,  and  when  present,  consist  of 
little  more  than  a  slight  frequency  and  an  occasional  tingling  or  burn- 
ing sensation  during  urination.  At  this  time  the  urine  is  usually  clear. 
Chronic  gonorrhea  of  Skene's  glands  does  not  generally  cause  pain. 

Spontaneous  cure  of  urethritis  undoubtedly  frequently  occurs; 
the  apparent  chronicity  in  some  cases  is  probably  due  to  reinfection 
by  the  discharge  from  the  more  intractable  cervical  lesions.  Sub- 
jective symptoms  vary  widely  in  different  cases,  and  even  in  acute 
attacks  are  often  quite  mild  and  transitory. 

A  point  of  importance  in  the  diagnosis,  and  therefore  in  the  treat- 
ment, of  chronic  cases  is  to  determine  the  point  of  origin  of  the  pus 
that  may  be  obtained  by  pressure  over  the  urethra;  this  usually  comes 

'  Finger:  Wien.  klin.  Wochenschr.,  1897,  No.  .3. 

■  Garceau:  Surg.,  Gyn.,  and  Obstet.,  January,  1912,  p.  SO. 

=  Taassig,  F.  J.:   Jour.  Mo.  State  Med.  A.ssoc,  November,  1912,  p.  137. 


PLATE  II 


^\-:|^>^!|^>ti». 


■'''Sfe^ 


rRETHRITIS    AND    BARTHOLINITIS. 

On  rflrartiiiK  the-  labia,  the  external  urinary  meatus  appear.**  a-i  a  reddeiuMl.  ck-vutcU  area. 
The  mucosa  is  tliiekened  and  more  or  lesa  everted.  Tina  is  especially  noticed  in  the  labia  of 
the  urt'thra.  The  exit  to  Bartholin's  glund  on  the  right  side  is  reddened,  and  presents  the 
typical  appearance  of  a  gonococcal  macule.  A  small  drop  of  pus  is  seen  exuding.  As  a  result 
of  the  irritating  discharge,  the  vulvar  orifice  is  seen  to  be  more  or  less  inflamed.  Tin-  infeetion 
of  the  crypts  about  the  urethra  is  well  illustrated. 


GONORRHEA    OF    THE    EXTERNAL   GENITALIA  209 

from  the  glands,  but  this  point  can  be  definitely  located  by  means  of 
a  cystoscope,  or  the  patient  may  be  instructed  to  urinate  and  the 
urethra  then  be  milked.  Urethritis  may  be  caused  by  organisms  other 
than  the  gonococcus.  SippeP  has  recently  directed  attention  to  the 
infection  of  the  urethra  by  the  colon  bacillus  which  often  occurs 
shortly  after  marriage. 

Treatment. — Urethritis  tends  to  become  chronic,  and  in  rare  cases 
maj'  eventuate  in  cure  without  any  treatment  whatever.  Neverthe- 
less, judicious  treatment  tends  to  shorten  the  duration  of  the  acute 
attack.  If  they  do  not  receive  treatment,  the  chronic  cases  often 
run  an  almost  interminable  course,  and  are  a  constant  source  of  danger 
both  to  the  patient  and  to  others.  It  is  this  type  of  case  in  which 
treatment  is  particularlj^  necessary  and  which  is  too  often  neglected. 
The  necessity  of  continuing  treatment  until  an  entire  cure  has  been 
obtained  cannot  be  overrated.  The  fact  that  at  this  stage  subjective 
symptoms  are  usually  absent  increases  the  difficulty  of  securing  per- 
sistent treatment . 

During  the  acute  stage  it  is  advisable  to  keep  the  patient  in  bed. 
If  this  cannot  be  done,  she  should  be  instructed  to  avoid  all  exercise  and 
take  as  much  rest  in  the  recumbent  position  as  possible.  The  diet  should 
be  restricted,  especial  care  being  taken  to  exclude  all  highly  seasoned, 
greasy,  or  fried  foods;  coffee,  tea,  acid  fruits,  and  vegetables  should  be 
intenhcted.  Alcohol  in  all  forms  must  be  avoided.  Skimmed  milk  is 
highly  recommended.  An  abundance  of  water  should  bedrunk,  with  the 
object  of  procuring  a  bland  urine.  Mineral  waters  are  often  beneficial  in 
these  cases,  not  so  much  perhaps  from  any  actual  medicinal  properties 
they  may  possess,  as  from  the  fact  that  patients  are  thus  induced  to 
drink  large  quantities  of  liquid.  To  guard  against  cystitis,  small  doses  of 
salol,  cystogen,  or  boric  acid,  or  combinations  of  these,  may  be  employed. 
The  l)owels  should  be  regulated  and  occasionally  flushed  by  the  use 
of  .salines.  The  use  of  rectal  enemata  is  contraindicated  in  all  gon- 
orrheal conditions  about  the  external  genitalia,  because  of  the  danger 
of  infecting  the  rectum.  Hot  sitz-baths  often  tend  to  alleviate  })ain 
when  this  is  pronounced.  Great  care  should  be  exercised  in  the  em- 
ployment of  local  treatment  not  to  contaminate  uninfected  organs, 
and  this  is  particularly  true  of  children.  If  the  cervix  is  coincidentally 
infected,  a  copious  weak  anti.septic  douche  should  be  administered 
two  or  three  times  daily.  If,  however,  the  cervix  and  \'agina  are 
normal,  every  precaution  should  be  exercised  to  keep  them  so,  and 
no  vaginal  douches  should  be  given. 

In  all  forms  of  urethral  treatment  care  must  be  taken  not  to  carry 

'  Sippel,  A.:   Deut.  med.  Wochenschr.,  June  13,  1912. 


210  > GONORRHEA    IN    WOMEN 

t}ie  infection  from  the  urethra  to  the  bladd(>r.  During  the  acute  stage 
cleanliness  and  irrigations  of  the  external  urinary  meatus  and  sur- 
rounding vulvar  structures  with  warm,  weak  antiseptic  solutions  are 
all  that  are  usually  necessary.  As  the  acute  symptoms  subside,  how- 
ever, more  active  measures  are  indicated.  These  consist  of  irrigations 
of  the  urethra  with  various  antiblennorrhagics,  among  the  best  of 
which  are  protargol,  0.5  to  5  per  cent.;  argyrol,  5  to  30  per  cent.; 
silver  nitrate,  2  to  5  per  cent.;  ichthyol,  10  to  50  per  cent.  Protargol 
and  argyrol,  owing  to  the  fact  that  they  may  be  employed  in  stronger 
solutions  and  are  less  irritating  to  the  inflamed  mucosa,  have  largely 
superseded  silver  nitrate.  The  injections  may  be  given  with  an 
ordinary  medicine-dropper  or  pipet,  care  being  always  taken  to  con- 
fine the  treatments  to  the  urethra,  and  not  to  wash  infective  material 
into  the  bladder.  The  injection  should  be  retained  for  from  two  to 
four  minutes.  The  patient  should  be  instructed  to  urinate  just  be- 
fore the  treatment  is  given  and  to  refrain  from  emptying  the  bladder 
for  at  least  one  hour  subsequently.  If  the  urethra  is  found  to  be 
sensitive,  or  if  the  treatments  cause  much  pain,  the  introduction  into 
the  canal  of  a  small  strip  of  cotton  soaked  in  weak  cocain  solution 
may  precede  the  treatment.  At  the  completion  of  the  irrigation  a 
small  pledget  of  cotton  soaked  in  the  germicidal  solution  may,  with 
advantage,  be  introduced  a  couple  of  centimeters  into  the  urethra 
and  left  in  place  for  half  an  hour  or  longer..  If  this  causes  much  pain 
or  irritation,  a  urethral  bougie  may  be  substituted  for  it.  These 
bougies  are  made  of  lanolin  or  cacao-butter,  softened  with  a  little  oil, 
to  which  is  added  protargol,  argyrol,  or  ichthyol,  as  the  case  may  seem 
to  demand. 

As  a  vehicle  for  applying  medications  to  the  urethra  the  bougie 
possesses  many  advantages.  After  they  are  inserted  the  wa'-inth  of 
the  tissues  causes  them  to  liquefy  slowly,  thereby  permitting  the 
medicament  to  come  into  intimate  contact  with  the  diseased  mucosa 
for  a  long  period  of  time.  Moreover,  the  oily  nature  of  the  excipient 
insures  the  contact  of  the  germicide  for  a  sufficiently  long  time  to 
permit  it  to  exert  its  full  effect,  as  the  oil  tends  to  penetrate  to  the 
deepest  crypts  of  the  urethra  and  to  adhere  to  the  mucosa. 

Hofman'  has  used  sodium  bile  salts  as  a  pus  solvent,  with  grati- 
fying results,  in  a  series  of  cases  of  urethritis  in  the  male.  He  believes 
that  the  bile  salts  act  particularly  well  in  removing  the  pus  and  mucus, 
thus  prei)aring  the  field  for  the  application  of  silver  or  other  ger- 
micidal preparations.  To  ascertain  the  efficacy  of  the  treatment 
the  urethra  should  be  examined  through  a  cystoscope,  the  canal  being 

'  HofmMii:  Wien.  klin.  Wochonsehr.,  I<tl2,  vol.  xxv,  No.  44,  p.  1742. 


GONORRHEA  OF  THE  EXTERNAL  GENITALIA  211 

first  irrigated  with  an  antiseptic  solution,  and  care  being  taken  not 
to  introduce  the  instrument  beyond  the  internal  sphincter.  To  pre- 
vent this,  the  barrel  of  the  cystoscope  should  not  be  inserted  more 
than  2  or  at  the  most  2.5  cm.  Frequently,  small  red  granular  areas 
of  ulceration  will  be  found.  These  should  be  treated  by  direct  appli- 
cations, through  the  cystoscope,  of  strong  solutions  of  silver  nitrate — 
5  to  10  per  cent.  These  applications  should  be  made  two  or  three 
times  a  week. 

In  most  cases  of  chronic  urethritis  Skene's  glands  will  be  found 
to  be  infected.  For  the  treatment  of  gonorrhea  in  this  location  a  few 
drops  of  a  5  per  cent,  protargol  solution  may  be  applied,  a  hypodermic 
syringe  with  a  blunt-pointed  needle  being  employed,  the  end  of  the 
needle  being  inserted  to  the  bottom  of  the  gland.  If  this  does  not 
effect  a  cure  in  a  reasonable  length  of  time,  the  plan  suggested  by 
Skene  may  be  used.  This  consists  of  introducing  a  fine  probe  to 
the  bottom  of  the  gland,  and  then  cutting  down  on  the  end  of  the  latter 
from  the  vaginal  side  by  means  of  a  cautery  blade.  The  gland  is  then 
thoroughly  burned  out.  This  operation  can  usually  be  performed 
under  local  anesthesia.  When  the  infected  area  can  be  easily  reached, 
and  when  the  external  urinaiy  meatus  is  large,  Skene's  glands  may  be 
opened  and  cauterized  through  the  urethra. 

In  examining  for  evidence  of  infection  in  Skene's  glands,  or  in  the 
treatment,  a  good  exposure  is  most  necessary.  Hunner'  suggests  the 
employment  of  two  bent  hair-pins  held  in  hemostats  for  retractors. 
Taussig-  prefers  an  Outerbridge  intra-uterine  pessarj-,  which  has  the 
advantage  of  being  self-retaining.  This  authority  recommends  in- 
jection of  10  to  20  per  cent,  silver  nitrate  solution  into  Skene's  glands, 
and  if  the  infection  does  not  quickly  yield  to  this  treatment,  the  in- 
cision of  the  glands  throughout  their  length  through  the  urethra. 
If  an  abscess  is  present,  this  should  be  opened,  and,  if  possible,  the 
opposite  gland  incised  at  the  same  sitting.  These  operations  can,  as 
a  rule,  be  performed  under  local  anesthesia. 

Stricture  of  the  female  urethra  is  of  comparatively  infrequent  oc- 
currence. It  is  generally  annular  in  type,  and  situated  near  the 
external  urinary  meatus,  although  any  part  of  the  canal  may  be  in- 
volved. The  most  marked  symi)tom  of  stricture  is  frequent  and 
difficult  micturition.  The  incontinence  of  retention,  so  fre(|uently 
observed  in  the  male,  may  be  pre.'^ent  also  in  the  female.  Induration 
about  the  site  of  the  stricture  can  usually  be  detected  by  palpation 

'Ilumicr,  G.  L.:  Ki^lly  iind  Noble:  Gynecology  and  Abdominal  Surgcrj',  Philadel- 
phia and  London,  l'.)()7,  vol.  i,  p.  4.tL 

•  Taussig,  F.  J.:  Jour.  .Mo.  State  Med.  Assoc.,  November,  1912,  p.  137. 


212  GONORRHEA   IN   WOMEN 

through  the  vagina,  or  the  stricture  may  be  located  by  means  of  a 
sound  or  with  the  urethroscope.  If  the  stricture  is  located  near  the 
external  urinary  meatus,  it  may  be  seen  by  direct  inspection.  Not 
infrequently  a  stricture  will  manifest  itself  only  when  an  old  infection 
is  lighted  up  or  a  fresh  infection  implanted  upon  the  urethral  mucosa. 
Strictures  can  usually  be  easily  dilated.  Forcible  dilatation,  with 
the  patient  anesthetized,  and  the  subsequent  daily  passage  of  a  sound 
for  a  short  period,  is  usually  preferable  to  gradual  dilatation.  In  rare 
instances,  owing  to  the  density  of  the  stricture,  urethrotomy  will 
be  demanded,  after  which  regular  dilatation  should  be  practised. 

During  the  chronic  stage  of  urethritis  general  treatment  is  of 
secondary  importance.  The  urine  should  be  kept  bland  by  the  means 
previously  described.  In  this  as  in  all  other  forms  of  gonorrhea  of  the 
genito-urinary  tract  the  patients  are  best  confined  to  bed  during  the 
menstrual  periods,  as  the  danger  of  extension  of  the  disease  is  greatest 
at  these  times. 

In  itself,  urethritis  is  frequently  a  very  mild  condition,  the  im- 
portance of  thorough  treatment  depending  not  so  much  on  checking 
the  subjective  symptoms  as  for  prophylactic  measures.  For  this 
reason  no  case  of  gonorrhea  of  the  external  genitalia  should  be  pro- 
nounced cured  until  so  proved  by  repeated  negative  bacteriologic 
examinations,  conducted  under  circumstances  favorable  for  the  de- 
tection of  the  gonococcus. 


CHAPTER  X 
GONORRHEAL  VAGINITIS  AND  CERVICITIS 

GONORRHEAL  VAGINITIS 
Gonorrheal  vaginitis,  colpitis,  or  elytritis  is  a  comparatively  rare 
disease  in  the  adult.  Among  pregnant  women  and  during  the  puerper- 
ium  the  condition  is  more  common.  Sanger^  states  that  vaginitis  is 
more  frecjueut  in  blonds  than  in  brunets.  This,  however,  has  never 
been  proved,  and  seems  on  a  par  with  the  somewhat  similar  state- 
ment made  bj'  Ricord,  in  1832,  to  the  effect  that  fair  women  were 
more  inceptive  to  venereal  infection  than  their  darker  sisters.  Vagi- 
nitis may  be  primary  or  secondary,  the  latter  form  being,  bj'^  far,  the 
more  frequent.  The  condition  usualh'  arises  as  the  result  of  the  con- 
stant contamination  of  the  vagina  by  discharge  from  a  gonorrheal 
cervicitis,  or,  less  often,  may  extend  upward  from  a  vulvitis  or  a  ure- 
thritis, which  conditions,  as  a  rule,  accompany  a  specific  vaginitis. 
The  gonococcus  is  the  microorganism  that  most  frequently  produces 
inflammation  in  this  locality.  The  comparative  infrequency  of 
vaginitis  in  adults  may  be  attributed  to  two  causes,  namelj^:  the 
bactericidal  properties  of  the  vaginal  secretion  and  the  fact  that  the 
vaginal  lining,  which  is  often  incorrectly  spoken  of  as  a  mucous  mem- 
brane, is,  in  general,  similar  in  its  histologic  structure  to  the  skin, 
except  that  in  the  former  there  are  verj^  few  glands  and  the  outer  layer 
of  epithelium  is  somewhat  less  fully  developed.  Because  of  this  latter 
reason  gonorrheal  infection  of  this  area  is  infrequent  in  adults,  whereas 
in  children,  in  whom  the  protective  qualities  of  the  lining  membrane 
of  the  vagina  are  but  poorly  developed,  gonorrhea  is  often  encountered. 
That  the  vaginal  secretion  is  destructive  to  pathologic  organisms 
has  been  proved  beyond  doubt. 

Doderlein  believes  that  the  acidity  of  the  normal  vagina  is  th(> 
result  of  the  production  of  lactic  acid  by  a  special  bacillus.  This 
observer  distinguishes  between  a  normal  and  a  pathologic  vaginal 
secretion.  The  former  is  strongly  acid,  whereas  the  latter  may  be 
weakly  acid,  neutral,  or  even  alkaline,  and  may  harlior  a  large  variety 
of  bacteria,  either  pathologic  or  saprophytic,  from  which  autoinfection 
may  take  place.  This  i)ath()logic  secretion  is  present  in  oO  per  cent, 
of  all  cases  of  pregnancy,  and  is  more  apt  to  occur  in  the  iiiullii)ara, 

'  .'^iingcr:  Veiliamll.  il.  ilcutsch.  Gcsellschaft  f.  (lyii.,  1.S.S9. 
213 


214  GONORRHEA    IN    WOMEN 

especially  if  the  vaginal  outlet  is  relaxed,  than  in  the  nullipara  or  the 
primipara.  The  demonstration  of  this  fact  has  greatly  simplified 
the  study  of  the  process  of  infection.  The  researches  of  Stolz'  and 
Dubendorfer^  have  in  the  main  confirmed  Doderlein's  conclusions 
regarding  the  bacteriology  of  the  vagina.  Labusquine'  has  also 
recently  called  attention  to  the  importance  of  the  acidity  of  the  vagina. 

At  certain  periods  in  a  woman's  life  the  vaginal  secretion  tends  to 
become  less  acid,  e.g.,  at  and  immediately  following  menstruation, 
during  the  puerperium,  and  when  a  profuse  leukorrhea  is  present — 
periods  when  it  is  well  recognized,  froin  clinical  experience,  that  the 
genital  tract  is  peculiarly  inceptive  to  any  form  of  infection,  and,  more 
especially,  to  the  gonococcus.  That  the  vaginal  secretion  has  bacteri- 
cidal properties  is  now  well  proved,  although  all  Doderlein's  conclu- 
sions are  not  universally  accepted.  Indeed,  Kronig  states  that  in  his 
investigations  he  was  unable  to  demonstrate  the  so-called  pathologic 
secretion,  and  that  the  vaginal  discharge  was  in  all  cases  equally 
bactericidal.  He  believes  that  the  diversity  in  results  obtained  is 
dependent  not  so  much  on  the  character  and  reaction  of  the  vaginal 
secretion  as  upon  the  vitality  and  virulence  of  the  germs.  His  in- 
vestigations were  made  upon  pregnant  women.  An  important  prac- 
tical observation,  reported  by  Kronig  and  since  confirmed  by  other 
investigators,  is  that  a  solution  of  mercury  bichlorid,  when  employed 
as  a  vaginal  douche,  destroys  the  germicidal  property  of  the  vaginal 
secretion,  probably  by  causing  a  precipitation  of  albumin,  whereas 
sterile  water,  employed  in  the  same  way,  tends  to  lessen  this  property. 
Menge  found  that  pathogenic  germs  in  the  vagina  were  destroyed  in 
periods  varying  from  two  and  one-half  hours  to  three  days.  His 
investigations  were  conducted  upon  non-pregnant  women. 

Williams'*  states  that,  under  normal  conditions,  pyogenic  cocci 
are  never  present  in  the  vagina  of  pregnant  women,  v.  Rosthorn^ 
believes  that  the  vagina  is  not  always  sterile.  Pankow^  is  of  the  opinion 
that  in  the  normal  woman  there  is  a  constant  inigration  of  organisms 
from  the  vulva  to  the  vagina,  but  that  in  the  latter  the  organisms  are 
destroyed.  At  the  outlet  of  the  vagina  a  few  germs  are  usually  present, 
but  become  more  and  more  scarce  as  the  depth  of  the  vagina  is  ap- 

'  Stolz:  Studien  zur  Bakteriologie  des  Genitalkanales  in  der  Schwangerschaft  und  im 
Wochenbett,  Graz,  1903. 

2  Dubendorfer,  E. :  Bakteriologische  Untersuchungen  des  Vulva  und  Vaginalsekretes, 
Inaug.  Diss.,  Bonn,  1901. 

=  Labusquine,  R.:  Annal.  de  Gyn.  et  d'Obstet.,  August,  1912,  p.  .503. 

*  Williams,  J.  W.:  Amer.  Jour.  Obst.,  1898,  vol.  x.\xviii:  also  Obstetrins,  p.  775,  New 
York  and  London,  1903. 

^  v.  Rosthorn;  von  Winckel,  Handbuch  d.  Geburtshiilfe,  1903,  vol.  i. 

''  Pankow:  Zcit.  f.  Geb.  u.  Gyn.,  1912,  vol.  Ixxi,  No.  3. 


GONORRHEAL    VAGINITIS    AND    CERVICITIS  215 

proached.  Pankow's  observations  bear  out  the  teachings  of  Doder- 
lein,  ^lenge,  and  Kronig  as  to  the  self-disinfection  of  the  vagina, 
^luch  investigation  has  been  carried  out  for  the  purpose  of  determining 
this  point.  Pankow's  conclusions  represent  the  most  modern  view 
concerning  the  bactericidal  properties  of  the  vaginal  secretion,  and 
are  accepted  by  the  majority  of  investigators.  Walthard  found  that 
streptococci  from  a  pure  culture  may  be  injected  into  the  ear  of  a 
rabbit  without  producing  serious  harm,  but  that  if  the  ear  was  pre- 
viously ligated  and  the  resistance  thus  lessened,  a  virulent  infection 
would  result.  He  compares  this  finding  with  that  obtained  when 
pathogenic  germs  are  introduced  into  the  normal  vagina  and  produce 
no  infection.  WTien,  however,  similar  microorganisms  are  brought 
in  contact  with  the  genitalia  immediately  after  the  trauma  and  injury 
incident  to  labor  a  virulent  infection  may  take  place,  a  familiar 
example  of  which  is  the  ordinary  postoperative  infection. 

From  what  has  been  said  it  may  be  seen  that  although  the  vaginal 
secretion  possesses  definite  germicidal  properties  that  are  more  pro- 
nounced at  certain  times  and  that  vary  under  different  conditions, 
the  exact  cause  or  process  by  which  the  microorganisms  are  destroyed 
has  not  been  conclusively  determined.  Lack  of  oxygen  can  hardly 
be  considered  an  important  factor,  despite  the  fact  that  the  bacteri- 
cidal properties  of  the  vaginal  "secretion  are  lessened  in  patients  in 
whom  the  introitus  is  gaping,  since  many  germs  that  are  anaerobic 
are  nevertheless  destroyed.  Nor  can  the  bactericidal  action  be 
explained  solely  by  the  chemical  composition  of  the  vaginal  secretion, 
as  the  reaction  of  the  latter  is  found  to  vary  quite  markedly;  neither 
does  it  seem  probable  that  this  destructive  power  is  entirely  dependent 
upon  the  action  of  a  special  bacillus,  although  some  microorganisms 
are  known  to  be  antagonistic  to  others.  According  to  Kronig,  the 
germicidal  property  of  the  vaginal  secretion  is  not  due  to  the  presence 
of  leukocjies,  as  it  has  been  found  to  continue  after  exposure  to  heat, 
which  destroys  the  contractile  power  of  the.se  cells.  Our  present 
knowledge  of  this  subject  would  seem  to  show  that  all  these  factors 
pl;iy  a  part  in  the  protection  of  the  vagina,  not  least  among  which 
sliould  be  mentioned  the  resistant  power  of  the  vaginal  lining  niem- 
lirane,  the  paucity  of  glands  in  this  location,  the  constant  outward 
flow  of  the  vaginal  secretion,  and  its  actual  germicidal  action. 

The  production  of  a  gonorrheal  vaginitis  is  usually  dependent 
upon  the  repeated  or  constant  application  of  the  specific  microorgan- 
isms to  the  parts,  in  conjunction  with  irritalion  or  injury,  or  upon 
some  general  condition  that  lessens  the  resistance  of  the  lining  mem- 
brane.    The  latter  is  the  cause  of  the  fretiuency  of  vaginitis  among 


216  GONORRHEA    IN    WOMEN 

children,  in  whom  the  membrane  is  thin  and  the  outer  layers  of  the 
squamous  epithelium  are  undeveloped.  The  frequency  of  vaginitis, 
either  specific  or  otherwise,  in  the  aged  may  be  attributed  to  the 
atrophic  changes  that  occur  in  the  lining  membrane  of  the  vagina. 

As  has  previously  been  stated,  gonorrheal  vaginitis  in  the  adult 
is  usually  a  secondary  condition  to  infection  of  the  cervix.  The  con- 
stant drenching  of  the  lining  membrane  of  the  vagina  with  the  dis- 
charge from  a  cervicitis  tends  to  soften  and  macerate  the  protective 
vaginal  epithelium,  and  is  an  important  etiologic  factor  in  the  pro- 
duction of  this  form  of  inflammation,  and  also  explains  why  the  disease 
nearly  always  occurs  secondarily.  Indeed,  Bumm  kept  gonococci 
in  the  vagina  of  an  adult  for  twelve  hours  without  producing  a  lesion. 
Sanger  believes  that  the  vagina  is  attacked  only  when  the  epithelium 
is  delicate,  thin,  or  of  impaired  vitality,  such  as  is  seen  in  the  young,  in 
the  old,  and  during  pregnancy.  Mandl  examined  tissue  taken  from 
cases  of  acute  gonorrheal  vaginitis,  and  found  that  the  squamous  epithe- 
lium was  invariably  thinned,  and  that  in  many  cases  the  papillse  were 
almost  exposed.  The  entire  sections  were  deeply  infiltrated  with  the 
products  of  inflammation,  and  gonococci  were  found  throughout  the 
thicknesses  of  the  epithelium,  many  being  within  leukocytes.  In 
some  areas  gonococci  were  observed  in  the  subepithelial  connective 
tissue.  The  gonococci  were  found  to  have  penetrated  most  deeply 
in  those  areas  in  which  the  protective  epithelium  was  thinnest. 

Symptoms.^Gonorrheal  vaginitis  may  be  acute,  subacute,  or 
chronic,  the  last  being  much  the  most  frequent  in  adults.  In  the 
acute  variety  the  onset  is  characterized  by  burning  pain  and  tender- 
ness, which  are  usually  referred  to  the  vulva  and  the  perineum.  These 
are  mild  at  first,  but  in  a  day  or  two  they  become  quite  severe,  and 
are  intensified  by  walking  or  exercise  of  any  kind.  At  the  outset  the 
discharge  is  scanty  and  thin,  but  it  soon  becomes  profuse,  mucopuru- 
lent, creamy  in  consistence,  greenish  or  yellowish  in  color,  and  in 
severe  cases  may  be  blood  streaked.  As  a  rule,  defecation  is  painful. 
Patients  occasionally  complain  of  a  sensation  as  of  a  foreign  body 
within  the  vagina.  Ardor  urinse  and  frequency  of  urination,  as  well 
as  other  symptoms  of  a  urethritis,  are  generally  present.  If  compUca- 
tions,  such  as  suppurative  adenitis  or  intraperitoneal  infection,  are 
absent,  the  constitutional  symptoms  are,  as  a  rule,  mild.  On  ex- 
amination the  vulva  is  often  found  to  be  involved,  and  th6  urethra 
usually  presents  evidences  of  inflammation.  The  lining  membrane 
of  the  vagina  is  swollen,  reddened,  and  exquisitely  tender.  On  palpa- 
tion, the  vagina  will  be  found  to  be  warmer  than  normally,  and  a 
vaginal  pulse  can  often  be  felt.     The  affected  parts,  as  well  as  the 


GONORRHEAL    VAGINITIS    AND    CERVICITIS  217 

introitus,  will  be  bathed  in  secretions.  The  hymen  or  the  carunculEe 
myrtiformes  are  thickened,  congested,  and  painful.  The  cervix  will 
nearly  always  be  found  to  be  the  seat  of  an  inflammation,  and  oc- 
casionally the  inguinal  lymph-glands  may  be  involved.  The  acute 
attack  usually  lasts  for  from  one  to  three  weeks,  and  if  not  properly 
treated,  gradually  merges  into  the  chronic  stage.  / 

Gonorrheal  vaginitis  may  be  subacute  from  the  onset,  and  may 
quickly  verge  into  a  chronic  condition.  In  chronic  vaginitis  the  symp- 
toms are  usually  combined  with  those  of  chronic  vulvitis,  bartholinitis, 
and  urethritis,  by  which  conditions  it  is  usually  accompanied.  At  this 
stage  all  the  symptoms  of  acute  inflammation  have  disappeared,  and 
the  vagina  is  no  longer  tender.  The  lining  membrane  is  slightly 
reddened  and  thickened,  and  in  some  cases  small  ulcers  or  areas  of 
erosion  may  be  present.  Finger  has  described  a  form  of  gonorrheal 
vaginitis  in  which  the  vagina  is  studded  with  deep-red  granules  the 
size  of  a  hemp-seed,  which  lend  to  the  surface  a  roughened,  granular 
appearance.  This  variety  of  vaginitis  is  most  common  in  pregnant 
women  or  in  those  who  are  anemic  or  poorly  nourished. 

Small  condylomatous-like  outgrowths  are  sometimes  observed  in  the 
vagina  during  the  subacute  or  chronic  stage.  Some  authors  claim 
that  these  are  characteristic  of  gonorrhea,  whereas  others  laelieve  that 
they  may  be  produced  by  any  long-continued  irritation,  and  are 
merely  the  morphologic  expression  of  chemical  irritation  of  the  papillse 
and  their  epithelial  covering.  Indeed,  in  this  connection  Bumm^ 
states  that  chronic  vaginitis  in  the  adult  is  not  so  much  the  result  of 
an  actual  infection  as  of  the  chemical  irritation  resulting  from  a  cer- 
vical discharge.  Some  authorities  believe  that  the  condition  may  be 
produced  entirely  by  the  toxins  in  the  discharge.  These  substances 
alone  undoubtedly  play  an  important  role  in  many  cases. 

During  the  chronic  stage  the  leukorrhea  is  decreased  in  amount, 
and  is  thinner  and  less  purulent  than  in  the  acute  stage.  The  more 
or  less  intense  pain  that  was  present  during  the  acute  stage  has  now 
given  place  to  itching  or  burning  sensations,  which  are  increased  by 
walking  or  friction,  and  are  relieved  by  rest  in  the  recumlient  position. 
Vaginismus  may  l)e  present,  and  is  especially  likely  to  occur  in  hysteric, 
neurasthenic,  or  debilitated  patients.  Attempts  at  coitus,  digital 
examination,  or  even  the  introduction  of  the  douche-nozle  may  pro- 
duce a  spasm  that  involves,  to  a  greater  or  less  extent,  all  the  muscles 
in  the  adjacent  area.  Vaginodynia  is  particularly  likely  to  occur 
in  tho.se  cases  in  which  ulcerations  or  fissures  comi)licate  the  vaginitis. 
Urethritis  sometimes  plays  a  part  in  the  prodviclion  of  the  spasm. 

'  Hmmii:   Quoted  by  Mcngc:  Handlnich  der  (ipschleclilskiiiiikluilcii,  \iciiiia,  lUH). 


218  GONORRHEA    IN    WOMEN 

The  various  symptoms  of  vuh-itis,  urethritis,  or  inguinal  adenitis 
may  be  present.  During  the  acute  stage  gonococci  in  large  numbers 
are  present  in  the  discharge,  but  later  they  are  reduced  in  number 
and  may  be  difficult  to  demonstrate  bacteriologically.  Exacerbations 
are  not  infrequent  during  pregnancy  or  menstruation,  and  are  often 
erroneously  regarded  as  fresh  attacks. 

Diagnosis. — Gonorrheal  vaginitis  must  be  distinguished  from 
inflammation  of  the  vagina  due  to  other  causes,  among  which  may 
be  mentioned  exogenous  irritation,  such  as  is  produced  by  pessaries, 
tampons,  and  the  like;  from  irritating  discharges,  such  as  occur  in 
cancer  of  the  uterus ;  from  a  ruptured  pelvic  abscess  that  is  discharg- 
ing its  contents  through  the  vagina;  from  discharges  from  vesico- 
vaginal, rectovaginal,  or  other  forms  of  vaginal  fistulas;  and  from 
uncleanliness.  An  etiologic  factor  to  be  borne  in  mind  in  vaginal 
inflammations,  especially  among  children,  is  the  Oxyuris  vermicularis, 
or  seat-worm.  The  use  of  caustics;  the  presence  of  decubitus  ulcers, 
such  as  are  often  found  in  cases  of  prolapse;  mycotic  infections; 
irritation  of  the  parts  by  dysenteric  discharges ;  the  ordinary  pyogenic 
microorganisms  or  the  Klebs-Loffler  bacillus — may  all  produce  the 
condition.  The  general  tendency  at  present  is  to  regard  all  forms 
of  vaginitis  as  dependent  upon  the  action  of  microorganisms,  foreign 
bodies,  etc.,  only  preparing  the  soil  for  subsequent  infections. 

The  diagnosis  of  gonorrheal  vaginitis  is  not  usually  difficult.  The 
history  of  the  case,  the  concomitant  symptoms  of  gonorrhea  of  the 
cervix,  Bartholin's  glands,  and  especially  of  the  urethra  and  possibly 
of  the  uterine  appendages,  and  the  absence  of  other  etiologic  factors, 
are  usually  sufficient  to  establish  the  identity  of  the  disease.  If  the 
vaginitis  occurs  during  the  puerperium  and  the  child  manifests  an 
ophthalmia,  this  is  an  almost  certain  indication  of  the  etiology  of  the 
vaginal  condition,  while  confrontation  in  some  cases  may  be  possible. 
As  regards  the  bacteriologic  demonstration  of  the  gonococcus  in  the 
discharge,  it  should  be  remembered  that  this  in  itself  is  not  sufficient 
proof  of  the  existence  of  a  vaginitis  in  the  adult,  as  the  specific  micro- 
organism may  be  recovered  from  the  discharges  in  cases  of  gonorrhea 
of  the  cervix  or  endometrium.  In  order  to  demonstrate  the  point  of 
origin  of  the  specific  microorganism  in  the  vaginal  secretions  Schultze's 
method  may  be  employed.  This  consists  in  thoroughly  cleansing 
the  vagina  and  external  genitalia  by  means  of  irrigations  and  swabbing, 
and  then  inserting  a  tightly  fitting  tampon  of  sterile  absorbent  cotton 
against  the  cervix.  If  the  secretion  that  collects  in  the  vagina  below 
the  tampon  contains  gonococci,  this  is  evidence  that  a  specific  vaginitis 
is  present,  whereas  if  the  upper  surface  of  the  tampon  is  contaminated 


GONORRHEAL    VACilXITIS    AND    CERVICITIS  219 

and  the  vaginal  secretion  is  found  to   be  negative,  the  infection  is 
obviously  confined  to  the  uterus  or  appendages. 

Treatment. — This  varies  with  the  stage  of  the  disease  present. 
A  thorough  examination  should  first  be  made  to  ascertain  the  extent 
of  the  lesion  and  to  determine  whether  it  is  primary  or  secondary. 
At  this  examination  a  specimen  should  be  secured  for  bacteriologic 
investigation.  If  the  condition  is  found  to  be  secondary,  treatment 
must  be  directed  to  the  primary  cause  as  well  as  to  the  vaginitis.  In 
most  cases,  when  the  cervical  or  ureteral  discharges  are  checked,  the 
vaginal  condition  will  improve  almost  at  once.  During  the  acute 
stage  absolute  rest  in  bed  is  indicated.  The  bowels  should  be  moved 
daily,  if  necessary  by  the  administration  of  a  simple  laxative,  or  an 
occasional  dose  of  Epsom  salts  may  be  given.  The  diet  should 
be  similar  to  that  recommended  in  acute  vulvitis.  As  urethritis  is 
usually  an  accompaniment  of  gonorrheal  vaginitis,  the  patient 
should  be  instructed  to  drink  large  quantities  of  water,  and  the  treat- 
ment directed  for  inflammation  of  the  urethra  should  be  instituted. 
If  the  suffering  is  severe,  small  doses  of  opium  may  be  administered. 
Suppositories  or  enemata  are  contraindicated  because  of  the  danger 
of  infecting  the  rectum.  For  purposes  of  cleanliness  and  in  order  to 
facilitate  the  local  treatment  it  is  usually  advisable  to  shave  the  vulva. 
An  aseptic  vaginal  douche,  consisting  of  a  gallon  of  some  bland  solu- 
tion, should  be  administered  twice  daily.  For  this  purpose  sterile 
water,  normal  salt  solution,  or  sodium  bicarbonate  (4  drams  to  the 
gallon)  may  be  employed,  or  if  it  does  not  cause  too  severe  pain,  a 
weak  antiseptic  solution,  such  as  Ij^sol  or  creolin  ( 1  dram  to  the  quart), 
mercury  bichlorid  (1 :8000),  boric  acid  (1  dram  to  the  quart),  or  boric 
acid  and  sodium  chlorid  (1  dram  of  each  to  the  quart),  may  be  sub- 
stituted. The  following  preparation,  known  as  the  A.  B.  C.  douche 
powder,  forms  the  basis  of  an  excellent  vaginal  irrigation  that  may  be 
used  in  all  forms  of  gonorrhea  in  whicli  a  douche  is  indicated: 

H .    .\c.  boric 5 vj 

Phenolis, 

Pulv.  alum.  cx.siccat aiSj 

Ol.  gaulth n] 

01.  inenth.  pip nv  xxx 

M.  S. — -Tablespoonful  to  a  gallon  of  water. 

The  strength  of  this  preparation  may  be  varied,  but  for  an  or- 
dinary vaginal  irrigation  the  foregoing  quantities  will  be  found  efficient. 
Polando'  states  that  the  efficacy  of  a  vaginal  douche  dei)ends  upon 
its  astringency — he  recommends  a  2  per  cent,  solution  of  alum.  Next 
in  order  of  merit  this  ob.server  places  a  4  per  cent,  solution  of  alcohol. 

'  I'olando:   /.■itschr.  f.  Ccl..  ii.  <!yn„  vol.  Ixx,  No.  1. 


220  GONORRHEA    IN    WOMEN 

If  there  is  no  nurse  in  attendance,  the  patient  should  be  instructed 
as  to  the  manner  of  taking  the  douche.  A  fountain  syringe  holding 
four  quarts  should  be  employed.  Glass  nozles  are  preferable  to  those 
made  of  hard  rubber,  as  they  are  more  easily  kept  clean.  Nozles 
should  be  of  medium  size,  and  have  perforations  at  the  side,  so  that  a 
recurrent  flow  will  be  obtained.  Nozles  with  an  opening  directly 
at  the  end  of  the  bulb  should  never  be  employed,  on  account  of  the 
danger  of  forcing  the  irrigating  solution  through  the  cervical  canal 
and  thus  infecting  the  uterine  cavity.  The  nozles  should  be  thoroughly 
washed  with  hot  water  and  soap  after  use,  and  then  placed  in  a  wide- 
mouthed  bottle  filled  with  an  antiseptic  solution.  This  bottle  should 
be  deep  enough  to  contain  sufficient  fluid  entirely  to  cover  the  nozles. 
The  douche-bag  and  tubing  should  be  scalded  well  before  and  after 
use,  and  when  not  in  use,  should  be  preserved  in  a  place  where  dust 
cannot  accumulate.  Only  boiled  water  should  be  used  for  douching 
purposes.  The  medicament  to  be  employed  is  best  dissolved  in  a 
cup  of  hot  water,  and  this  mixture  added  to  the  required  water  in 
the  douche-bag.  By  this  method  the  drug  is  thoroughly  dissolved 
and  mixed  with  the  water  that  is  to  be  used.  The  water  should, 
as  a  rule,  have  a  temperature  of  from  105°  to  110°F.  The  douche- 
bag  should  be  hung  at  a  height  that  will  require  fifteen  minutes  for 
two  quarts  of  solution  to  run  off,  and  twenty  or  twenty-five  minutes 
for  a  gallon.  As  a  rule,  three  or  four  feet  is  about  the  proper  height. 
The  douche  should  be  taken  with  the  patient  in  the  recumbent  posture, 
the  hips  being  elevated.  Care  should  be  observed  to  keep  the  douche- 
nozle  sterile.  The  labia  should  be  separated  before  the  nozle  is  in- 
troduced. A  good  plan  is  to  have  detailed  directions  for  taking  a 
douche  printed  and  hand  a  copy  to  each  patient.  A  douche-pan  is 
essential.  Under  no  circumstances  should  an  irrigation  be  taken 
while  the  patient  is  on  the  toilet  or  in  the  bath-tub.  The  latter  may 
seem  an  unnecessary  warning,  but  many  cases  have  been  known  to 
occur  where  this  has  been  the  custom. 

The  vulvar  pads  should  be  changed  frequently  and  the  soiled 
dressing  burned.  Prophylactic  measures,  as  suggested  under  the 
treatment  of  vulvitis,  should  be  carried  out,  especial  care  being  ob- 
served lest  the  pus  be  carried  to  the  eyes.  As  the  acute  symptoms 
being  to  subside,  more  active  local  treatment  is  indicated.  Vaginal 
irrigations  of  weak  antiseptic  solutions  may  now  be  employed  three 
or  more  times  daily.  Formalin  (40  minims  to  the  quart),  creolin  or 
lysol  (1  per  cent.),  mercury  bichlorid  (1 : 8000),  boric  acid  and  sodium 
chlorid  (1  dram  of  each  to  the  quart),  potassium  permanganate  (1 
dram  to  the  quart),  or  the  A.  B.  C.  douche  are  to  be  recommended  for 


GONORRHEAL   VAGINITIS    AND    CERVICITIS  221 

this  purpose.  In  addition  to  the  vaginal  irrigations,  local  applications 
are  of  serA'ice.  These  are  best  given  with  the  patient  in  the  Sims' 
or  knee-chest  position;  after  the  vagina  has  become  distended  with 
air,  which  should  occur  as  soon  as  the  Sims'  speculum  is  introduced, 
the  entire  lining  membrane  should  be  freely  sprayed  with  one  of  the 
anti-blennorrhagics  advised  for  the  treatment  of  chronic  vulvitis, 
lodin,  2  grains  to  the  ounce  of  95  per  cent,  alcohol,  answers  very  well 
for  this  purpose  if  the  vagina  be  not  too  sensitive.  The  spray  is  more 
effective  than  simple  swabbing,  as  by  its  means  the  solution  is  driven 
into  all  the  crypts  and  folds  of  the  vagina.  In  Polak's^  clinic  a  sat- 
urated solution  of  picric  acid  has  been  employed  with  satisfactory 
results.  In  about  100  cases  of  gonorrhea  of  the  vagina  in  which  the 
gonococcus  was  found  in  pure  culture,  from  three  to  five  treatments 
with  picric  acid  cleared  the  field  entirely  of  the  gonococci.  The 
method  employed  was  very  simple:  the  vagina  was  thoroughly 
cleansed;  a  tubular  speculum  was  introduced,  and  one  or  two  ounces 
of  a  solution  of  argj-rol  were  poured  into  the  vagina.  Then  a  suitable 
piece  of  gauze  was  soaked  in  a  saturated  solution  of  picric  acid  in 
glj'cerin  and  placed  in  the  vagina. 

If  chronic  ulcers  or  abrasions  are  present,  these  may  be  touched 
with  the  solid  stick  of  silver  nitrate.  This  treatment  should  be 
thorough,  and  repeated  two  or  three  times  a  week.'  After  the  evening 
irrigation  it  is  often  of  advantage  to  introduce  a  vaginal  tampon 
.saturated  in  one  of  the  following  preparations:  Ichthyol  and  lanolin 
(25  per  cent,  to  50  per  cent.) ;  argyrol  (25  per  cent.) ;  protargol  (10  per 
cent,  to  20  per  cent.);  silver  nitrate  (2  per  cent,  to  5  percent.);  or 
formalin  in  glycerin  and  water  (formalin,  30,  minims;  gl.ycerin,  6 
ounces;  water,  14  ounces).  Intelligent  patients  may  be  taught  how 
to  prepare  and  insert  the  tampons.  For  this  purpose  the  antiseptic 
gelatin-coated  tampons,  filled  with  sterile  wool,  are  best.  In  some 
cases,  when  the  vagina  is  tender,  ointments,  such  as  carbolized  vase- 
lin  (5  per  cent.),  boric  acid  in  vaselin,  or  ichthyol  (10  per  cent.)  and 
formalin,  may  be  substituted  for  the  more  active  antiseptics.  The 
tampon  should  be  removed  in  the  morning  before  the  douche  is  taken. 
In  these  cases  Asch-  employs  bougies  containing  5  to  20  per  cent,  of 
isoform,  with  excellent  results.  This  drug  is  said  to  be  especially 
efficacious  in  the  treatment  of  vulvovaginitis  in  young  girls. 

In  order  to  increa.se  the  amount  of  lactic  acid  in  the  vagina,  Kuhn' 
recommends  the  api)licati()n  of  sugar.  This  method  is  of  value  chiefly 
in  the  early  stages  of  tlic  infection,  ami  does  not  prevent  the  eniploj^- 

'  Polak :  Personal  communication. 

'  .\.s(,'li:  Zentralbl.  f.  Gyn.,  vol.  xxxiv,  No.  12,  p.  400. 

'  Kiilin:   Zcit.  f.  Ccl).  u.  Gyn.,  vol.  Ixx,  No.  1. 


222  GONORRHEA    IN    WOMEN 

ment  of  other  forms  of  treatment.  The  treatment  of  urethritis  and 
other  gonococcal  lesions  that  may  be  present  should  not  be  neglected. 
It  is  important  that  these  patients  be  kept  under  treatment  until  a 
complete  cure  has  been  effected,  as  gonorrhea  in  any  form,  but  es- 
pecially that  of  the  cervix  and  vagina,  is  a  frequent  source  of  infection, 
and  the  patient  herself  is  in  constant  danger  of  the  disease  extending 
upward  toward  the  peritoneal  cavity.  The  fact  should  not  be  lost 
sight  of  that  the  discharge  from  these  cases  is  infectious,  and  every 
precaution  should  be  taken  to  prevent  contamination  of  others.  If 
the  patient  is  married,  an  effort  should  be  made  to  have  the  husband 
examined  and,  if  necessary,  treated.  Coitus  should  be  interdicted, 
and  when  this  is  impossible,  precautionary  measures  should  be  adopted. 

VAGINAL  CONDYLOMATA 
These  tumors  may  be  present  in  the  vagina,  and  may  or  may  not 
accompany  a  vaginitis.  They  may  be  secondary  to  a  gonorrhea  of  the 
cervix,  or  may  extend  inward  from  a  vulvitis  or  from  similar  growths 
of  the  external  genitalia.  As  compared  with  venereal  warts  of  gon- 
orrheal origin  on  the  external  genitalia,  condylomata  in  the  vagina 
are  infrequent.  The  growths  present  the  same  general  appearance 
as  do  those  found  on  the  labia  or  the  perineum.  Occasionally  they 
are  somewhat  flattened,  depending  upon  their  location.  These  tumors 
are  most  frequently  obser^•ed  in  the  lower  third  of  the  vagina,  al- 
though no  part  of  the  canal  is  exempt.  If  any  doubt  as  to  the  nature 
of  the  growths  exists,  a  microscopic  examination  will  clear  up  the 
diagnosis.  The  treatment  is  similar  to  that  recommended  for  condy- 
lomata of  the  external  genitals.  In  extensive  excisions  care  must  be 
observed  that  the  vagina  is  not  unduly  narrowed,  either  by  the  opera- 
tion or  by  the  subsequent  scar.  Concomitant  gonorrheal  lesions 
should  receive  appropriate  treatment. 

GONORRHEAL  CERVICITIS 
Gonorrheal  infection  of  the  cervix  is  usually  of  primary  origin, 
although  ascending  infections,  starting  at  the  external  genitalia,  have 
been  described.  From  its  location,  the  cervix  is  obviously  an  area 
in  which  contamination,  resulting,  as  gonorrhea  usually  does,  from 
coitus,  is  most  likely  to  take  place.  The  portio  vaginalis,  being 
normally  covered  by  squamous  epithelium  to  or  slightly  above  the 
external  os,  is  unlikely  to  become  primarily  infected  by  the  gonococcus, 
an  organism  that  shows  a  strong  predilection  for  the  columnar  epi- 
thelium. The  canal  is  lined  with  columnar  epithelium,  and  this  is 
the  area  in  which  the  infection  originates  in  the  nulliparous  women, 

V 


GONORRHEAL   VAGINITIS    AND    CERVICITIS  223 

SO  that  the  primary  infection  is  usually  an  endocervicitis  rather  than 
a  cervicitis.  From  here  it  may  spread  by  continuity  to  the  surface  of 
the  cervix  immediately  surrounding  the  external  os,  and  upward  to 
the  endometrium  and  to  the  tubes  and  ovaries.  The  process  of  up- 
ward extension  is  usually  checked,  at  least  temporarily,  by  the  con- 
striction at  the  internal  os.  Other  factors  that  tend  to  control  the 
upward  spread  of  the  disease  are  the  constant  downward  flow  of  the 
cervical  and  uterine  secretions,  the  plug  of  cervical  mucus,  and  per- 
haps the  strong  alkalinity  of  the  uterine  cavity,  for  it  is  well  known  that 
gonococci  that  have  been  accustomed  to  an  even  faintly  acid  medium 
do  not  grow  well  in  an  alkaline  soil.  The  vaginal  portion  of  the  cervix 
is  usually  bathed  in  an  acid  secretion,  whereas  the  uterine  cavity  is 
alkaline.  The  exact  point  at  which  this  change  in  reaction  occurs 
in  the  cervical  canal  varies  in  different  cases.  In  a  case  of  extensive 
bilateral  laceration  with  marked  eversion  of  the  mucosa  and  gaping 
of  the  external  os  the  acid  reaction  of  the  vagina  naturally  extends 
higher  in  the  canal  than  in  a  nulli]:)ara  in  whom  the  cervical  opening 
is  small  and  contracted. 

The  cervix  is  one  of  the  most  frequent  structures  in  the  female 
genital  tract  to  be  invaded  by  the  gonococcus,  as  shown  by  McCann' 
and  others.  Menge,-  quoting  the  combined  statistics  of  Bumm, 
Steinschneider,  Fabry,  Briinschke,  Brose,  and  Welander,  found  that 
the  cervix  was  involved  in  SO  per  cent,  of  acute  and  in  95  per  cent,  of 
chronic  cases. 

The  disease  may  be  acute  or  chronic,  the  latter  being  the  more  fre- 
quent form.  Sanger,  Doderlcin,  and  other  authorities  claim  that  gonor- 
rheal cervicitis  may  be  chronic  from  the  beginning.  This  is  denied  by 
Menge.  Theoretically,  this  observer  is  undoubtedly  con-ect,  but  prac- 
tically it  is  found  that  the  virulence  of  the  disease  varies  markedly,  and 
that  although  all  cases  are  probably  acute  at  the  onset,  in  some  the 
initial  symptoms  are  so  mild  as  closely  to  approach  the  chronic  type. 
This  is  true  of  gonorrhea  in  all  parts  of  the  genital  tract. 

^^^len  the  disease  is  acute,  the  chief  symptom  is  generally  the 
presence  of  a  profuse,  thick,  yellowish,  purulent  discharge,  which 
contains  polymorphormclear  leukocytes,  Ij'mphocytes,  and  epithelial 
debris,  and  that  may  at  times  be  blood  streaked.  This  exudate  con- 
tains luunerous  tyi)ical  gonococci.  At  this  stage  of  the  disease  the 
cervix  may  be  swollen  and  tender.  At  and  surrounding  the  external 
OS  a  soft,  bright-red  area  will  be  found  thai  is  more  prominent  than 

'  McC.inn,  I".  .1.:  Trans.  London  ()l>sl.  Soc,  ISilG,  vol.  xxxviii,  p.  241. 
-  Mcn(ic,  K.:   Hniidliuch  d.  (icscldechtskrankheiten,  Vienna,  1910. 
'  Dodcrlt'in:  Quoted  by  Menge:  Loc.  cil. 


224  GONORRHEA    IN    WOMEN 

the  surrounding  tissue  (Plate  III),  and  may  bleed  slightly  if  trauma- 
tized by  the  examining  finger.  The  edges  of  this  area  are  not  sharply 
defined,  and  small  punctate  spots  may  be  observed  extending  from 
it  over  the  adjacent  portio.  In  the  center  of  this  area  of  inflammation 
is  the  external  os,  from  which  the  mucosa  of  the  canal  may  be  seen 
protruding  as  a  bright  red  spot  of  everted,  thickened,  and  congested 
inflammatory  tissue.  Purulent,  thick,  tenacious  secretion  is  nearly 
always  present  in  the  canal,  and  may  be  seen  extruding  from  the  ex- 
ternal OS.  Pressure  on  the  cervix  usually  causes  pain.  In  those  cases 
in  which  there  has  been  an  extensive  laceration  of  the  cervix  a  some- 
what more  complex  picture  is  often  observed.  In  addition  to  the 
usual  evidences  of  laceration  and  eversion,  the  mucous  membrane  of 
the  canal  may  be  greatly  swollen;  the  arbor  vitse  may  be  unusually 
prominent,  and  the  inflamed  area  will  appear  to  be  more  extensive 
than  if  lacerations  were  not  present.  Constitutional  symptoms  are 
rarely  marked  and  are  generally  absent.  Slight  tenderness  and 
pain  in  the  inguinal  lymphatic  glands  and  iliac  regions  at  the  men- 
strual periods  is,  according  to  Brettauer,^  a  frequent  symptom  of 
gonorrhea  of  the  cervix  or  the  external  genitaUa.  This  pain  is  often 
accompanied  by  a  slight  rise  in  temperature,  and  is  distinctly  different 
from  the  usual  dysmenorrheic  symptoms  encountered  in  young  women.  / 
Menstruation  may  be  irregular  and  profuse.  Gonorrheal  cervicitis, 
may  be  chronic  almost  from  the  outset.  In  the  chronic  stage  leukor- 
rhea  is  often  the  only  symptom  present.  This  discharge  is  not  so 
profuse  as  in  the  acute  stage,  and  is  usually  mucopurulent  and  whitish 
or  yellowish  in  color.  Gonococci  in  reduced  numbers  are  present  in 
the  exudate,  and  can  often  be  demonstrated  only  after  prolonged 
search.  In  chronic  cervicitis  acute  exacerbations  are  particularly 
likely  to  occur  at  and  following  the  menstrual  periods,  during  preg- 
nancy, in  the  puerperium,  or  following  unwise  cervical  manipulations, 
at  which  times  the  discharge  is  increased  in  amount  and  becomes 
more  purulent.  Gonococci  can  usually  be  demonstrated  in  the  exudate 
at  these  periods,  even  in  those  cases  in  which  numerous  previous 
bacteriologic  examinations  have  given  a  negative  result.  During 
the  chronic  stage  pain  is  rarely  observed,  and  tenderness  is  much  less 
noticeable  or  may  be  absent.  Menstruation  may  and  frequently  is 
irregular,  and  the  flow  may  be  increased  in  amount.  Marked  men- 
strual disturbances  are,  however,  more  Ukely  to  occur  after  extension 
to  the  corporeal  endometrium.  Profuse  leukorrhea  is,  without  doubt, 
a  debilitating  condition.  The  numerous  reflex  nervous  symptoms, 
however,  that  are  sometimes  ascribed  to  this  discharge  should  be  ac- 

'  Brettauer,  S.:  Amer.  Jour.  Obst.,  September,  1911,  p.  4.57. 


I 


PLATE  111 


AcrxB  GoNoiiKHKAL  Cbkvicitih  and  Uukthritis. 
The  cervix  in  noriniil  or  enlarged.     The  area  surrounding  the  external  os  is  reddened  and 
conKfttted.     The  reddened  area  blcnda  gradually  into  the  Hurrounding  uormul  cervical  tissue. 
The  urethra  is  somewhat  reddened  and  the  mucosa  everted. 


GONORRHEAL   VAGINITIS    AND    CERVICITIS  225 

cepted  with  great  caution,  as  they  are,  as  a  rule,  too  vague  to  warrant 
much  consideration.  Cervicitis  often  causes  steriUty.  The  general 
appearance  of  the  cervix  is  similar  to  that  of  the  acute  stage,  but  the 
condition  is  more  chronic.  Hypertrophy  of  the  cervix  is  less  frequent, 
and  the  congestion  is  not  so  well  marked  as  in  the  acute  stage.  As 
a  consequence  of  infection,  the  orifices  of  the  cervical  gland  often  be- 
come occluded,  and  small  cystic  formations  that  vary  in  size  from 
that  of  a  pinhead  to  a  buck-shot  or  larger  result.  These  cysts  can 
sometimes  be  observed  bulging  out  from  the  cervical  tissue  beneath 
the  squamous  epithelium  of  the  portio,  and  can  be  palpated  as  hard, 
shot-like  bodies.  If  punctured,  the  cyst  will  exude  a  drop  of  thick, 
tenacious  mucus,  which  may  or  may  not  be  purulent.  Nabothian 
cysts  may  result  in  marked  enlargement  of  the  cervix,  and  are  espe- 
cially likely  to  be  present  in  conjunction  with  extensive  lacerations. 
In  some  cases  of  chronic  gonorrhea  of  the  cervix  the  lesions  are  so 
slight  that  they  can  be  detected  only  with  the  greatest  chflfiiculty. 

Diagnosis. — Cervicitis  is  usually  readily  diagnosed.  To  prove 
that  the  condition  is  of  gonorrheal  origin  is,  however,  not  always  so 
easy,  especially  during  the  chronic  stage.  The  historj'  of  the  case 
and  the  application  of  suitable  bacteriologic  tests  will  generally  clear 
up  this  point.  When  the  gonorrhea  is  superimposed  upon  a  laceration 
and  eversion  of  the  cervix,  the  diagnosis  is  sometimes  rendered  ex- 
tremely difficult.  The  presence  of  a  congenital  erosion  of  the  cervix 
may  also  complicate  the  clinical  picture.  It  should  always  be  borne 
in  mind  that  in  cervicitis  of  gonorrheal  origin  the  urethi-a  and 
Barthohn's  glaiuls  are  usualh^  involved.  Severe  cases  of  cervicitis 
occurring  in  multipara;  may  at  times,  on  account  of  the  discharge, 
irritation,  and  profuse  menstruation,  suggest  tumor  formation,  espe- 
ciallj'  carcinoma,  and  the  differential  diagnosis,  even  after  the  cervix 
is  exposed,  is  not  alw;ws  easily  made.  Both  lesions  may  bleed  on 
touch,  although  carcinoma  is  more  likely  to  do  so.  In  carcinoma, 
however,  the  cervix  is  hard,  whereas  in  cervicitis  or  in  cervicitis  with 
eversion  it  is  soft.  In  the  former  there  is  an  actual  loss  of  tissue, 
whereas  in  the  latter  the  diseased  area  is  swollen  and  nabothian  cysts 
are  usually  present. 

The  history,  the  age  of  the  patient,  the  absence  or  presence  of 
concomitant  sj'inptoms  of  gonorrhea  in  other  parts  of  the  genital 
tract,  and  tlu;  phy.sical  character  of  the  lesions  will  almost  invariably 
clear  up  the  diagnosis.  If  any  doul)t  exists,  a  histologic  examination 
of  a  piece  of  excised  tissue  will  furnish  al)solute  proof  of  the  character 
of  the  condition.  Early  1ul)erculosis  of  the  cervix  may  also,  in  some 
cases,  cau.se  confusion.  In  this  location,  however,  tul)erculosis  is  ex- 
1.') 


226  GONORRHEA    IN    WOMEN 

tremely  rare.  Syphilis  usually  presents  characteristics  that  differ- 
entiate it  from  gonorrheal  cervicitis.  In  cases  of  doubt,  the  labora- 
tory offers  a  means  of  positive  diagnosis. 

Treatment. — In  acute  gonorrhea  of  the  cervix  no  local  treatment, 
save  cleansing  vaginal  irrigations  of  bland  antiseptic  solutions,  is 
indicated.  As  exceptions  to  this,  however,  must  be  mentioned  those 
rare  cases  in  which  the  cervical  lesions  are  discovered  in  their  incipi- 
ency,  in  which  case  the  method  of  Polak^  often  gives  excellent  re- 
sults. This  consists  in  placing  the  patient  in  the  elevated  lithotomy 
position  and  pouring  into  the  vagina,  through  a  Ferguson  speculum, 
a  solution  of  25  per  cent,  argyrol.  The  excess  of  the  argyrol  is  then 
removed,  and  an  absorbent  cotton  tampon  saturated  with  a  solution 
consisting  of  equal  parts  of  glycerin  and  picric  acid  is  applied  to  the 
cervix.  This  tampon  is  reinforced  by  another  of  lamb's  wool.  The 
tampons  are  left  in  place  for  twenty-four  hours,  and  the  treatment  then 
repeated.  By  this  method  gonorrhea  of  the  external  portion  of  the  cer- 
vix may  often  be  cured  in  a  short  time,  but  when  the  disease  has  ex- 
tended to  the  deep  mucosa  of  the  canal,  the  treatment  becomes  much 
less  effective. 

When  gonorrheal  cervicitis  is  chronic,  every  effort  should  be  made 
to  eradicate  the  disease.  Whatever  form  of  local  treatment  is  in- 
stituted during  the  chronic  stage,  it  is  of  the  utmost  importance,  as 
a  preliminary  step,  that  the  thick  cervical  mucus  be  removed,  as  its 
presence  to  a  large  extent  nullifies  the  beneficial  effects  of  all  medica- 
tion by  acting  as  a  protective  medium  for  the  gonococcus,  and  pre- 
venting the  application  from  reaching  the  diseased  areas.  For  this 
reason,  before  applications  are  directed  toward  the  cervix,  this  struc- 
ture should  be  exposed  by  means  of  a  suitable  speculum,  and  the 
portio  and  external  os  sprayed  with  an  alkahne  solution.  This  pro- 
cedure should  be  followed  by  swabbing  of  the  canal  with  pledgets  of 
cotton  until  all,  or  nearly  all,  the  mucus  has  been  removed.  To 
facilitate  the  treatment  it  is  advisable  to  steady  the  cervix  by  grasping 
it  with  a  double  tenaculum  forceps.  The  success  of  the  treatment  of 
cervical  gonorrhea  largely  depends  upon  the  thoroughness  with  which 
this  preliminary  cleansing  is  carried  out.  Dobell's  solution  or  a 
solution  of  sodium  borate  and  sodium  bicarbonate,  of  each,  1  dram  to 
6  ounces  of  water,  may  be  employed.  For  application  to  the  cervix  and 
cervical  canal  moderately  strong  antiseptic  solutions  give  the  most 
satisfactory  results;  among  the  best  of  these  are  tincture  of  iodin, 
pure  ichthyol,  silver  nitrate,  1  dram  to  the  ounce,  zinc  chlorid,  20  to 
50  per  cent.,  or  formaldehyd,  37  to  40  per  cent.     Since  the  cervix 

'Polak:  Personal  communication. 


GONORRHEAL    VAGINITIS    AND    CERVICITIS  227 

is  practically  non-sensitive,  these  solutions  may  be  applied  with  im- 
punity without  causing  pain.  After  the  removal  of  the  thick,  tena- 
cious cervical  mucus  the  vagina  should  be  protected  by  the  appUca- 
tion  of  vaselin,  and  the  cervix  and  canal  dried  with  pledgets  of  ab- 
sorbent cotton,  and  a  piece  of  cotton  or  small  gauze  sponge  placed 
posterior  to  the  cervix.  An  applicator  should  then  be  wrapped  with 
a  thin  laj^er  of  absorbent  cotton  and  the  solution  applied  to  the  dis- 
eased area  and  to  the  canal.  Care  must  be  taken  not  to  insert  the 
applicator  beyond  the  internal  os,  but  it  should  be  pressed  in  every 
direction  against  the  cervical  mucosa.  Sufficient  medication  should 
be  used  to  reach  all  the  crypts  in  the  canal.  If  tincture  of  iodin,  ich- 
thyol,  or  silver  nitrate  solution  is  employed,  a  pledget  of  absorbent 
cotton  or  narrow  strip  of  gauze  saturated  in  this  solution  may,  with 
advantage,  be  left  in  the  canal  for  five  or  ten  minutes,  the  vaginal 
speculum  being  meanwhile  kept  in  place.  When  the  external  os  is 
small,  it  is  well  to  dilate  the  lower  portion  of  the  cervical  canal  prior 
to  making  the  application,  so  as  to  permit  the  treatment  to  be  more 
thoroughly  applied.  This  dilatation  may  be  effected  with  the  solid 
metal  dilator.  Superficial  cysts  or  nabothian  follicles  should  be 
punctured  with  a  spear-pointed  bistoury  or  scaljiel  and  their  contents 
pressed  out.  This  treatment  should  be  followed  by  the  introduction 
of  a  tampon,  which  may  be  left  in  place  for  from  ten  to  fourteen 
hours.  The  cervical  portion  of  the  tampon  should  be  saturated  with 
one  of  the  following  solutions:  Ichthyol,  25  to  50  per  cent.;  argyrol, 
25  per  cent.;  or  protargol,  10  to  25  per  cent.  For  office  work  the 
tampons  put  up  in  gelatin  capsules,  now  manufactured  by  the  various 
supply  houses,  are  not  only  convenient,  but  are  especially  efficacious, 
as  none  of  the  solution  is  squeezed  out  during  the  process  of  intro- 
duction. These  treatments  should  be  given  once,  twice,  or  thrice  a 
week.  Applications  should  be  begun  three  or  four  days  after  the 
cessation  of  menstruation,  and  are  best  discontinued  a  few  da3's  be- 
fore the  expected  onset  of  a  period.  The  patients  should  be  instructed 
to  take  three  vaginal  douches  daily,  except  during  menstruation: 
one  in  the  morning  on  arising,  one  in  the  middle  of  the  day,  and  the 
last  l)efore  retiring  at  night.  (For  the  technic  of  administering 
vaginal  douches  sec  under  the  Treatment  of  Vaginitis.)  A  vaginal 
douche  should  not  he  administered  while  a  tampon  is  in  place.  The 
irrigation  should  consist  of  solutions  similar  to  those  recommended 
for  chronic  vaginitis,  the  best  of  which,  perhaps,  is  the  A.  B.  ('.  douche. 
Strict  asepsis  should  be  maintained  throughout  the  treatment.  Kven 
after  apparent  cure  has  taken  place  the  treatment  .should  be  conliiuKMl 
for  some  weeks.     A  case  should  be  considered  cured  onlv  after  all 


228  GONORRHEA    IN    WOMEN 

clinical  symptoms  have  disappeared  and  at  least  three  consecutive 
negative  bacteriologic  examinations,  conducted  under  cn-cumstances 
favorable  for  the  detection  of  the  gonococcus,  have  been  performed. 
Bruneti  reports  good  results  from  the  use  of  pure  picric  acid  in 
these  cases,  and  Abraham-  recommends  bougies  containing  yeast  and 
aspargin  The  latter  has  treated  200  cases  of  gonorrhea  of  the  cervix 
or  vagina  with  yeast,  and  beheves  that  by  this  method  better  results 
are  obtained  than  by  the  employment  of  any  other  means.  His 
method  is  first  to  clean  and  dry  the  parts,  and  then  to  insufflate 
powdered  yeast  over  the  vaginal  walls  and  cervix.  As  a  final  step,  a 
glycerin  suppository  containing  3  grams  of  yeast  powder  is  inserted 
against  the  cervix.  This  method  is  especially  efficacious  m  the  treat- 
ment of  vulvovaginitis  of  children.  As  the  result  of  experiments, 
Abraham  found  that  when  gonococci  are  brought  in  contact  with 
yeast,  they  are  destroyed  in  six  hours;  hence  he  believes  that  yeast 
possesses  a  positive  bactericidal  power. 

Martin^  employs  steriUzed  yeast  applied  on  a  tampon,  and  espe- 
cially recommends  its  use  in  cases  of  gonorrhea  of  the  cervix  complicat- 
ing pregnancy.  The  yeast  is  unirritating.  This  investigator  prefers 
sterile  normal  salt  solution  for  vaginal  irrigation.  Menge,^  on  the 
other  hand,  states  that  yeast  has  been  employed  more  or  less  ex- 
tensively by  himself  and  his  assistants  in  his  clinic.  No  definite  cure 
by  the  use  of  yeast  alone  has  ever  been  obtained  in  any  of  their  cases. 
Wagner"  recommends  irrigation  of  the  cervix  by  means  of  hot  water. 
He  employs  a. wire  frame  to  distend  the  vagina,  and  irrigation  with 
large  quantities  of  hot  sterile  water  once  daily,  20  to  25  liters  at  45°  C. 
being  employed  at  a  treatment.  Once  a  week  mucus  from  the  cervix 
is  examined  for  gonococci,  and  the  treatment  is  continued  until  no 
specific  organisms  have  been  found  on  three  consecutive  examinations. 
In  85  per  cent,  of  Wagner's  cases  the  gonococci  had  disappeared  in 
from  twenty-six  to  thirty-five  days,  and  by  the  ninetieth  day  in  all 
others.  The  method  seems  to  be  pecuUarly  effective  for  gonorrheal 
vaginitis  in  little  girls.  Watson''  recommends  the  treatment  of  gonor- 
rheal cervicitis  by  lactic-acid  bacilh.  The  preparation  that  he  employs 
is  made  by  filtering  "Saurkultur"  made  of  skimmed  milk.  Filtering 
separates  the  casein  and  leaves  a  slightly  opaque  whey,  which  con- 
tains large  numbers  of  lactic-acid  bacilli  as  well  as  lactose,  lactalbumen, 

1  Brunet:  Poitou  ined.  Poitiers,  1910,  vol.  xxv,  pp.  10-12. 

-  Abraham:  Monats.  f.  Geb.  u.  Gyn.,  vol.  xxxi. 

'  Martin:  Berlin,  klin.  Woohenschr.,  1904,  No.  13,  p.  32o. 

<  Menge,  K.:  Hand.  d.  Geschleohtskrankheiten,  Vienna,  1910. 

'  Wagner:  Berlin,  klin.  Wochenschr.,  Berlin,  December  25,  1911,  No.  52. 

«  Watson:  Brit.  Med.  Jour.,  January  22,  1910. 


GONORRHEAL   VAGINITIS    AND    CERVICITIS  229 

and  salts.  The  solution  thus  obtained  can  be  strengthened,  by  the 
addition  of  powdered  lactic  acid  if  deemed  necessary.  Watson  first 
thoroughly  cleanses  the  cervix  and  then  applies  the  lactic-acid  solu- 
tion. The  treatment  is  administered  daily.  He  reports  excellent 
results  from  this  treatment.  Nassauer*  strongly  urges  the  dry  treat- 
ment of  cervical  gonorrhea,  and  states  that  he  utilizes  this  method  in 
nearly  all  cases  in  which  he  formerly  used  tampons.  He  employs 
bolus  alba  because  it  is  an  impalpable  powder  and  has  a  high  absorptive 
power. 

Constitutional  treatment  is  not  usually  required  in  gonorrheal 
cervicitis.  The  bowels  should  be  regulated  and  general  hj'gienic 
measures  instituted.  In  the  debilitated  or  anemic,  tonics  containing 
iron  and  strychnin  are  indicated.  Von  Franque-  recommends  that 
I  mud-baths  be  taken  twice  a  week.  It  is  especially  important  that 
these  patients  be  kept  in  bed  during  the  menstrual  periods.  If  this 
is  found  to  be  impossible,  they  should  be  confined  to  their  rooms  and 
all  unnecessary  exercise  be  interdicted;  all  forms  of  local  treatment 
should  be  discontinued,  and  every  effort  be  made  to  prevent  the  disease 
from  spreading  to  the  body  of  the  uterus. 

Gonorrheal  cervicitis  is  often  extremely  intractable,  and  persists 
despite  all  palliative  measures  that  may  be  adopted.  If  this  is  found 
to  be  the  case,  trachelectomy  will  have  to  be  resorted  to.  Amputa- 
tion of  the  cervix  offers  the  best  hope  of  cure  in  those  cases  in  which 
palliative  methods  fail  to  produce  satisfactory  results  after  a  fair  trial. 
Hunner'  recommends  the  destruction  of  the  cervical  glands  by  the 
actual  cautery.  The  method  he  employs  is  suitable  for  office  use,  and 
does  not  require  the  administration  of  an  anesthetic.  His  technic 
is  as  follows:  With  the  patient  in  the  dorsal  position,  a  broad-bladed 
Sims'  speculum  is  introduced  and  the  anterior  lip  of  the  cervix  grasped 
with  a  tenaculum  and  pulled  down  as  far  as  possible.  The  nurse  or 
a.ssistant  stands  at  hand  with  the  heated  cautery.  On  handing  the 
cautery  to  the  operator  the  assistant  continues  to  work  the  bulb  with 
one  hand,  while  with  the  other  she  retracts  the  s])eculum.  The 
operator  steadies  the  cervix  with  the  tenaculum  ami  manages  the 
cautery  with  the  other  hand.  The  strokes  should  l)e  made  one  at  a 
time,  the  cautery  Ix'ing  removed  from  the  vagina  after  each  ai)plication, 
as  the  patient  feels  the  radiated  heat  on  the  vaginal  walls.  The 
l)atient  should  be  warned  that  she  will  feel  the  heat,  but  must  be  told 
not  to  move,  as  there  w  ill  be  no  pain.    An  exceiilioii  to  this  rule  is  found 

'  Ni'.-suucr:   Miinch.  mod.  Wochcnschr.,  1912,  No.  Id  iml  11. 

=  Vim  I'ninipi.-;  ('entrall)l.  f.  (lyn.,  HtOfi,  No.  :«. 

'  lluiiMcr:  .lour,  .\iiicr.  .Mid.  As.sor.,  .Jiiniiiuy  20,  HHHl,  p.  I'.M. 


230  GONORRHEA    IN    WOMEN 

in  those  patients  who  are  suffering  from  a  painful  cervical  scar.  Wlaen 
this  condition  is  present,  Hunner  advises  a  preliminary  application 
of  20  per  cent,  cocain  solution.  Five  or  six  strokes  are  made  at  each 
sitting.  The  strokes  are  radiating,  and  are  from  2  to  5  mm.  in  depth, 
and  vary  in  length  according  to  the  case.  Treatments  are  given  once 
in  three  weeks.  Occasionally  slight  bleeding  follows  the  treatment, 
and  as  a  precautionary  measure,  a  strip  of  gauze  may  be  left  in  the 
vagina  for  twenty-four  hours  following  the  cauterization.  Discharge 
is  usually  profuse  for  a  few  days  following  the  treatment.  An  aver- 
age of  ten  treatments  are  required. 

Schindler^  believes  that  the  uterus  possesses  a  definite  rhythmic 
automatic  movement  not  influenced  by  the  central  nervous  system, 
and  that  this  action  accounts  for  many  of  the  endometrial  and 
adnexal  gonorrheal  infections.  His  conclusions  are  based  upon  an 
extensive  series  of  experiments  which  he  has  reported  in  detail. 
Atropin  has  been  found  to  paralyze  these  movements.  He  therefore 
recommends  that  this  drug  be  administered  in  the  acute  stage  of 
gonorrheal  infections,  and  at  such  times  as  extension  upward  is  likely 
to  take  place,  as,  for  example,  after  the  emptying  of  a  pregnant  uterus 
in  a  patient  known  to  have  a  cervical  gonorrhea.  Drenkhahn-  also 
employs  this  drug  in  puerperal  cases.  Schindler'  has  employed 
atropin  extensively  in  a  large  series  of  acute  gonorrheal  lesions,  and 
has  never  observed  any  ill  effects  following  its  use,  and  beheves  that 
it  is  of  great  benefit  to  such  patients. 

PRURITUS  VULV^ 
Itching  or  burning  of  the  external  genitalia  may  occasionally  be 
secondary  to  gonorrhea  of  the  upper  genital  tract,  producing  a  profuse 
discharge.  Mild  degrees  of  pruritus  vuIvje  are  by  no  means  infre- 
quent, especially  in  neglected  cases,  and  in  children  may  lead  to  mas- 
turbation. The  author  has  never  seen  any  very  severe  cases  of  this 
condition  that  were  due  to  gonorrhea  alone.  Sanger*  believes  them 
infrequent.  When  the  discharge  is  checked,  the  condition  rapidly 
disappears,  and  the  only  treatment  usually  necessary  is  that  directed 
to  the  primary  gonorrhea  and  the  accompanying  vulvitis.  When  the 
itching  or  burning  is  extreme,  a  temporary  application  of  phenol  and 
menthol,  of  each,  10  grains  to  the  ounce,  or  50  per  cent,  turpentine 
ointment,  may  be  employed  until  the  discharge  is  checked.  Clean- 
liness is  essential. 

'Schindler,  C:    Arch.  f.  Gjni.,  Borlin,   1900,  vol.  Ixxxvii.  p.  007;    also  Berlin,  klin. 
Woch.,  1909,  vol.  xlvi,  p.  1691. 

-  Drenkhahn:  Therap.  Monatsh.,  Felinuiry,  1905. 

»  Schindler,  C;   Loc.  cil.  *  Siinger:  Cent.  f.  Gynak.,  1894,  p.  154. 


I 


GONORRHEAL    VAGINITIS    AND    CERVICITIS  231 

CONDYLOMATA  OF  THE  CERVIX 
Winter  and  Ruge' refer  to  condylomata  of  the  cervix;  tlie  condition 
is,  however,  extremely  rare.  Until  1900  Cullen-  had  only  observed  one 
case,  and  this  was  associated  with  tuberculosis.  The  tumors  occur  most 
frequently  during  pregnancy,  and  resemble  condylomata  of  the  ex- 
ternal genitalia  or  vagina.  They  vary  in  shape  and  are  often  pedun- 
culated. They  are  usually  secondary  to  cervical  gonorrhea.  On 
account  of  the  rarity  of  condylomata  of  the  cervix,  all  tumors  spring- 
ing from  this  location,  and  especially  those  that  present  a  cauliflower- 
hke  appearance,  should  be  subjected  to  histologic  examination  in 
order  to  exclude  the  possibility  of  cancer.  Venereal  warts  of  this 
area  may  be  excised  and  the  wound  closed  with  interrupted  catgut 
sutures. 

'  Winter  and  Ruge:  Gynecological  Diagnosis. 
2  Cullen:  Cancer  of  the  Uterus,  1900,  p.  191. 


CHAPTER  XI 

GONORRHEAL  ENDOMETRITIS,  METRITIS,  AND  INTRAMURAL 
UTERINE  ABSCESS 

GONORRHEAL  ENDOMETRITIS 

Strictly  speaking,  endometritis  may  be  either  cervical  or  corporeal. 
Although  both  forms  of  the  disease  may  be  set  up  by  the  same  micro- 
organism, the  pathology,  symptoms,  prognosis,  and  treatment  are 
totally  dissiiTiilar.  In  a  preceding  chapter  we  dealt  with  gonorrheal 
inflammations  of  the  cervix,  and  in  order  to  avoid  confusion  these 
conditions  were  designated  cervicitis  and  endocervicitis,  in  contra- 
distinction to  the  term  endometritis,  which  is  here  reserved  for  an 
inflammation  of  the  corporeal  endometrium. 

The  name  endometritis  was  formerly  used  to  cover  practically 
all  endometrial  diseases  except  actual  tumor  formation.  This  led  to 
much  confusion  and  to  many  unnecessary  and  often  actually  harm- 
ful operations.  Much  of  this  confusion  doubtless  arose  as  the  result 
of  the  indiscriminate  histologic  diagnosis  made  upon  specimens 
secured  by  curetage,  such  as  glandular,  interstitial,  fungoid,  hy- 
perplastic, or  atrophic  endometritis.  Such  diagnoses  were  usually 
based  upon  a ,  misconception  of  the  normal  histology  of  the  en- 
dometrium. Since  the  excellent  monograph  of  Adler  and  Hitsch- 
mann,'  whose  findings  were  confirmed  by  Keene-  and  the  author, 
a  clearer  understanding' of  the  histology  of  the  normal  endometrium 
has  resulted.  It  is  now  known  that  the  changes  in  the  endome- 
trium run  in  a  definite  cycle,  the  details  of  which  have  been 
described  under  the  Pathology  of  Endometritis.  It  is  sufficient  for 
present  purposes  to  state  that  the  mucosa  removed  shortly  before  a 
menstrual  period  will  be  found  to  be  thick  and  present  all  the  appear- 
ances of  what  was  formerly  frequently  incorrectly  designated  as 
glandular  or  hyperplastic  endometritis,  whereas  the  post-menstrual 
endometrium  will  be  found  to  be  thin  and  of  the  type  often  spoken 
of  as  atrophic  or  interstitial  endometritis.  Another  cause  for  con- 
fusion has  been  the  application  of  the  term  endometritis  to  such 
endometria  as  are  thickened  or  altered  as  a  result  of  variations  in 
the  blood-supply  and  from  causes  other  than  actual  inflammation. 

'  Adler  and  Hitsclimann:  Monats.  f.  Geb.  u.  Gyn.,  1908,  vol.  xxvii,  No.  1. 
=  Xorris,  C.  C,  and  Kcene,  F.  E.:  Surg.,  Gyn.,  and  Obstet.,  January,  1909,  p.  -14. 
232 


GONORRHEAL    ENDOMETRITIS  233 

The  general  trend  at  present  is  to  view  all  forms  of  endometritis  as  the 
products  of  bacterial  infection,  and  in  this  opinion  the  author  concurs. 
When,  therefore,  the  term  endometritis  is  used  here,  it  will  be  intended 
to  designate  a  condition  induced  by  the  direct  action  of  bacteria. or 
their  toxic  products  upon  the  endometrium.  As  a  result  of  our  more 
accurate  knowledge  of  the  histology  of  the  endometrium,  we  now  recog- 
nize that  inflammation  of  this  structure,  instead  of  being  extremely 
frequent,  as  was  formerly  believed,  is  actually  of  comparative  rarity. 
This  is  particularly  true  of  the  gonorrheal  conditions  unassociated 
with  tubal  inflammation. 

Gonorrheal  endometritis  is  always  the  result  of  an  ascending  in- 
fection, the  cervix  being  invariably  previously  attacked.  From  the 
endometrium  the  disease  may  and  often  does  spread  to  the  tubes, 
where  it  produces  the  various  inflammatory  lesions  of  the  adnexa. 
In  the  histologic  examination  of  many  endometria  from  cases  of 
pyosalpinx  the  mucosa  of  the  uterus  was  found  to  be  normal  in  a  con- 
siderable proportion  of  specimens,  thus  leading  to  the  belief  that  in  a 
certain  percentage  of  cases  gonorrhea  in  this  locality  undergoes  spon- 
taneous cure,  although  Bumm'  and  others  have  proved  that  the 
gonococci  may  in  some  instances  lie  dormant  without  setting  up  an 
inflammatory  reaction.  This  Jatter  explanation  is  doubtless  the 
c(jrrect  one  in  many  cases.  It  seems  probable  that  the  resolution 
of  the  endometrium  depends  largely  upon  the  perpendicular  arrange- 
ment of  the  uterine  cavity,  which  favors  drainage,  and  the  abun- 
dant blood-supply  of  the  mucous  membrane.  Active  inflammation 
of  the  endometrium  is  not  infrecjuently  kept  up  in  cases  of  pyosalpinx 
by  the  leakage  of  pus  through  the  intramural  portion  of  the  tube  into 
the  uterine  cavity. 

The  actual  fre(iuency  of  endometritis  is  shown  l)y  the  fact  that 
in  the  Laboratory  of  Clj-necologic  Pathology  at  the  University  of  Penn- 
sylvania, the  author  has  examined  995  endometria  removed  for 
various  conditions,  and  ainong  this  number  he  found  only  20S  cases 
of  endometritis,  12  being  of  puerperal  origin,  whereas  14  were 
tui)ercular.  Of  the  194  cases  (tubercular  cases  excluded),  including 
those  of  puerperal  origin,  121,  or  ()2.3()  per  cent.,  were,  judging  from  the 
clinical  symptoms,  gonorrheal  in  origin.  Of  the  12  puerperal  cases, 
ti  were  associated  with  the  presence  of,  and  were  probably  caused  by, 
the  gonococcus.  All  the  cases  examined  have  not  been  subjected  to 
bacteriologic  tests,  so  that  it  is  impossible  to  state  positively  the  pro- 
portion of  these  infections  that  were  of  gonorrheal  origin.  Almost 
similar  results  regarding  the  frequency  of  endometritis  are  reported 

'  Uiinim:  Vril's  Il.uiil.  ilcr  ( ivii. 


234  GONORRHEA    IN    WOMEN 

by  CuUen,  who  states  that  during  a  period  of  four  years  in  the  Gyneco- 
logic Laboratory  of  the  Johns  Hopkins  Hospital,  there  were  only  48 
cases  of  endometritis,  or  an  average  of  one  a  month.  When  we  con- 
sider that  neither  of  these  reports  refers  exclusively  to  gonorrheal  con- 
ditions, the  comparative  infrequency  of  this  type  of  infection  of  the 
endometrium  is  at  once  apparent.  Of  the  194  cases  of  endometritis 
previously  referred  to,  101  were  associated  with  more  or  less  involve- 
ment of  the  uterine  musculature.  Metritis  must,  therefore,  be  re- 
garded as  a  frequent  accompaniment  of  endometritis.  Of  the  141 
cases  of  endometritis  that  were  associated  with  inflammatory  lesions 
of  the  tubes,  and  which,  it  seems  fair  to  assume,  may,  at  least  in  the 
large  majority  of  cases,  be  considered  of  gonococcal  origin,  71  were 
complicated  by  metritis.  It  is  important  to  bear  in  mind  the  relative 
infrequency  of  endometritis  compared  with  cervicitis,  and  the  associa- 
tion of  the  former  with  metritis  and  often  with  adnexal  lesions,  in 
considering  the  treatment  of  this  condition.  In  previous  years  a 
lack  of  knowledge  of  this  point  led  to  the  indiscriminate  emploj^ment 
of  intra-uterine  applications  and  the  performance  of  curetments, 
which  have  often  been  followed  by  the  most  disastrous  results  in 
cases  in  which  the  source  of  the  trouble  really  lay  in  the  cervix.  Leip- 
mann^  states  that  about  50  per  cent,  of  the  cervical  gonorrheas 
eventually  extend  above  the  internal  os.  In  the  large  series  of  cases 
reported  upon  by  the  Committee  of  Seven-  invasion  of  the  uterine 
cavity  and  adnexa  had  occurred  in  40  per  cent,  of  patients.  Opitz' 
believes  that  not  more  than  10  per  cent,  of  gonorrheas  extend  above 
the  internal  os. 

Gonorrheal  endometritis  may  be  either  acute  or  chronic,  and 
varies  in  severity  quite  markedly  in  different  cases.  Chronic  endo- 
metritis may  result  from  an  acute  attack  or  may  be  practically  subacute 
or  chronic  from  the  onset. 

Acute  Gonorrheal  Endometritis 
Symptoms. — The  disease  usually  makes  itself  manifest  shortly 
following  a  labor,  miscarriage,  or  abortion,  or  just  after  a  menstrual 
period.  In  some  cases  the  infection  of  the  endometrium  occurs  during 
menstruation,  in  which  event  an  abrupt  cessation  of  the  flow  may 
take  place  or  the  period  may  be  prolonged  or  profuse.  At  the  men- 
strual periods,  and  following  the  emptying  of  a  pregnant  uterus,  the 
cervix  is  softened,  the  canal  unusually  patulous,  and  the  plug  of 
cervical  mucus  less  occlusive,  conditions  that  favor  extension  of  the 

'  Loipmann:   Monats.  f.  Hautkrankh.,  1904,  vol.  i. 

=  Med.  News,  Decenibor  2.  1909.  '  Opitz,  E.:  Medizinische  Klinik,  .January  S,  1911. 


GONORRHEAL   ENDOMETRITIS  235 

infection  from  below.  In  former  years,  when  intra-uterine  office 
manipulations  and  treatment  were  in  general  vogue,  infection  fre- 
quently resulted  from  such  procedures  by  carrying  infection  from  the 
cervix  to  the  body  of  the  uterus.  Cameron'  states  that  endometritis 
is  likeh'  to  follow  extra-uterine  pregnancy.  As  the  uterus  during 
extra-uterine  gestation  undergoes,  although  to  a  lesser  extent,  many 
of  the  changes  common  to  normal  pregnancy,  such  as  slight  enlarge- 
ment, slight  .softening  of  the  cervix,  etc.,  the  etiologic  relationship 
between  the  two  concUtions  can  easily  be  understood.  In  acute 
gonorrheal  endometritis  constitutional  symptoms  are,  as  a  rule, 
present.  The  condition  is  sometimes  ushered  in  by  a  chill,  which  is 
not  often  severe.  Pyrexia  is  almost  invariably  present,  although  the 
temperature  rarely  rises  above  101.5°  F.  The  pulse  ranges  from  100 
to  115,  and  the  frequency  of  respiration  is  usually  correspondingly 
increased.  The  concomitant  symptoms  of  fever  are  present.  Nausea 
and  vomiting  may  occur,  especially  if  the  infection  is  a  severe  one. 
Diarrhea  and  rectal  or  vesical  tenesmus  may  be  present.  Pain  is  not 
marked,  but  is  nearly  always  complained  of  over  the  lower  abdomen, 
chiefly  in  the  region  of  the  uterus.  If  the  acute  attack  occurs  during 
a  menstrual  period,  irregularities  are  frequently  observed,  these 
usually  taking  the  form  of  an  excessive  flow.  The  leukorrhea,  which 
at  the  very  onset  may  be  diminislw^d,  soon  becomes  profuse^  The 
discharge  coming  from  the  endometrium  can  be  distinguished  from 
that  originating  in  the  cervix  by  its  thinness  and  the  lack  of  the  tena- 
cious, glairy  mucus  that  is  so  characteristic  of  the  cervical  secretion. 
-As  cervical  gonorrhea  is  almost  invariably  an  accompaniment  of 
endometritis,  the  discharge  from  the  body  of  the  uterus  and  from  the 
cervix  are  usually  intimately  mixed.  In  such  cases  the  discharge  is 
often  very  profuse,  mucopurulent,  or  purulent  in  character,  and  in 
grave  cases  it  is  sometimes  l)l()od  streaked.  It  is  made  up  of  mucus, 
serum,  epithelial  debris,  and  pus,  and  contains  typical  gonococci, 
which,  during  the  acute  stage,  can  usually  l)e  demonstrated  without 
difficulty.  At  this  stage  a  pelvic  examination  will  disclose  the  fact 
that  the  uterus  is  sliglitly  enlarged,  uniformly  softened,  and  tender, 
and  the  cervix  hypertrophied  and  the  canal  more  patulous  than  normal. 
Evidences  of  gonorrhea  in  the  urethra  or  external  genitalia  are  nearly 
always  present,  and  gonococci  may  sometimes  be  recovered  from  these 
locations  when  their  tlemonstration  in  the  uterine  discharge,  by  the 
ordinary  methods,  is  difficult  or  impossible.  Owing  to  the  mixture 
of  the  cervical  and  corporeal  discharges,  but  little  dependence  can  be 
placed  upon  the  demonstration  of  gonococci  in  the  leukorrhea,  unless 

'  Cameron:    Brit.  Mi.l   .lour.,  VMV.K  vol.  ii,  p.  lO'JS. 


236  GONORRHEA    IN    WOMEN 

the  material  for  examination  is  secured  directly  from  the  body  of  the 
uterus,  a  procedure  that  in  most  cases  is  hazardous. 

Diagnosis. — Acute  gonorrheal  endometritis  is  to  be  differentiated 
from  septic  endometritis,  the.  typical  variety  of  which  is  produced  by 
the  streptococcus.  The  latter  almost  invariably  follows  as  the  result  of 
contamination  of  the  uterine  cavity  by  manipulations,  and  is  usually 
preceded  by  labor  or  iniscarriage.  Gonorrheal  endometritis  may  be 
further  distinguished  from  the  septic  form  of  the  disease  by  the 
milder  and  more  chronic  symptoms  of  the  former,  the  concomitant 
evidences  of  gonorrhea  in  other  portions  of  the  genital  tract,  by  the 
presence  of  the  specific  microorganisms  in  the  exudates,  and  by  the 
tendency  of  the  gonorrheal  form  to  become  chronic.  Acute  gonorrheal 
endometritis  frequently  extends  to  the  tubes,  but  the  positive  diag- 
nosis of  this  complication  during  the  acute  stage  is  often  difficult. 
The  points  that  would  suggest  a  spread  of  the  infection  to  the  adnexa 
are  extension  of  pain  to  the  ovarian  regions,  severity  and  persistence 
of  the  symptoms,  and  the  demonstration,  by  vaginal  examination,  of 
enlarged  and  tender  tubal  lesions.  If  a  bimanual  examination  is 
performed  at  this  stage,  it  should  be  carried  out  with  the  utmost 
gentleness,  because  of  the  danger  of  spreading  the  infection.  Indura- 
tion in  the  vaginal  fornices,  fixation  of  the  cervix,  and  marked  tender- 
ness in  these  areas  are  signs  indicative  of  an  extension  of  the  disease 
beyond  the  uterus.  Small  intra-uterine  tumors,  especially  if  they 
are  undergoing  degenerative  changes,  sometimes  produce  subjective 
symptoms  similar  to  acute  gonorrheal  endometritis.  Their  differ- 
ential diagnosis  is,  however,  usually  easy. 

Treatment. — The  treatment  of  acute  gonorrheal  endometritis 
is  mainly  expectant.  The  patient  should  be  confined  to  bed.  The 
bowels  should  be  regulated  by  the  use  of  mild  cathartics  and  an 
occasional  dose  of  the  salines.  The  diet  should  be  regulated,  and 
should  include  the  drinking  of  plenty  of  water.  To  aid  drainage  of 
the  uterine  cavity  the  patient  may  with  advantage  be  placed  in  the 
upright  Fowler  position.  If  this  is  found  to  cause  much  discomfort, 
the  position  may  be  assumed  for  half  an  hour  two  or  three  times  a  day. 
The  posture  should  be  somewhat  modified  in  the  individual  case 
according  to  the  position  of  the  uterus.  Thus  if  the  uterus  is  in  ante- 
position,  the  extreme  upright  posture  will  not  give  so  good  drainage 
as  if  the  patient  is  inclined  slightly  backward,  while  if  the  uterus  is  in 
retroposition,  the  perpendicular  or  the  Sims  left  lateral  posture  is  the 
most  beneficial.  No  special  medication  by  mouth  is  usually  required. 
If  the  constitutional  symptoms  are  marked  or  shock  is  present,  stimu- 
lating treatment  may  be  indicated.     This,  however,  is  not  the  rule. 


i 


GONORRHEAL  ENDOMETRITIS  237 

as  such  symptoms  are  indicative  of  a  streptococcic  rather  than  of  a 
gonococcal  infection.  If  the  temperature  is  high,  cold  sponges  may  be 
employed. 

To  relieve  the  pain  and  to  hasten  the  subsidence  of  the  inflamma- 
tion ice-bags  or  ice-coils  maj^  be  applied  over  the  lower  abdomen.  In 
some  cases  the  application  of  heat  in  the  form  of  turpentine  stupes  or 
large  poultices  is  preferable.  Whichever  method  gives  the  greatest 
comfort  to  the  individual  patient  is  the  one  to  be  adopted.  The  ex- 
ternal genitalia  should  be  kept  clean  by  the  use  of  irrigations  of  weak 
antiseptic  solutions,  such  as  those  previously  directed  in  the  treat- 
ment of  vulvitis.  If  the  discharge  is  profuse,  cleansing  vaginal  irriga- 
tions of  physiologic  normal  salt  solution  of  a  temperature  of  about 
110°  F.  should  be  employed  once  or  twice  daily.  During  the  early 
stages,  or  when  the  cervical  canal  may  be  widely  open,  the  douches 
are  best  administered  with  the  patient  in  Fowler's  position,  great  care 
being  exercised  not  to  drive  the  fluid  forcibly  into  the  vagina  for  fear 
of  washing  the  vaginal  discharge  into  the  uterine  cavity.  If  any 
doubt  exists  as  to  the  possibility  of  confining  the  irrigations  to  the 
vagina,  douches  had  best  be  omitted  at  this  stage.  The  chief  in- 
dication is  to  keep  the  vagina  clean.  A  sterile  vulvar  pad  should  be 
appUed.  All  soiled  dressings  should  be  burned,  and  the  precautionary 
measures  recommended  for  the  treatment  of  acute  gonorrhea  of  the 
external  genitalia  should  be  instituted.  Under  this  plan  of  treatment 
the  acute  symptoms  usually  subside  in  from  five  days  to  a  week. 

Chronic  Gonorrheal  Endometritis 

This  condition  may  occur  as  a  se(iuela  of  an  acute  process,  or  may 
originate  as  a  subacute  attack.  Like  acute  gonorrheal  endometritis, 
the  disease  is  always  associated  with  gonorrhea  of  the  cervix.  Acute 
exacerbations  may  occur  at  any  time,  but  are  most  frequent  after 
abortion,  miscarriage,  labor,  or  at  the  menstrual  periods,  or  the  at- 
tacks may  follow  improperly  applied  intra-uterine  manipulations  or 
rough  pelvic  examinations. 

Symptoms. — The  chief  symptom  of  chronic  gonorrheal  endome- 
tritis is  the  persistent  leukorrhea.  The  discharge  is  less  in  amount 
and  not  so  purulent  as  in  the  acute  condition.  At  this  stage  of  the 
disease  it  is  often  extremely  difficult  to  distinguish  between  the  dis- 
charge of  a  cervicitis  and  that  of  an  endometritis.  In  the  latter  con- 
dition the  discharge;  is  whitish  or  yellowish  in  color,  and  thiiuun-  than 
that  originating  in  the  cervix,  although,  as  a  rule,  the  discharges  are 
intimately  mixed.  Microscopic  examination  of  tiie  secretion  shows 
lliat  it  is  composed  of  serum,  epithelial  debris,  leukocytes,  and  oc- 


238  GONORRHEA   IN   WOMEN 

casionally  a  few  red  blood-corpuscles.  According  to  Adler  and 
Hitschmann/  and  Norris  and  Keene,'-  normally  no  mucus  is  se- 
creted by  the  endometrium  except  near  the  menstrual  periods; 
any  mucus  that  is  present,  therefore,  is  mainly  of  cervical  origin. 
It  is  often  only  after  repeated  search  that  gonococci  can  be  detected 
in  the  discharge.  This  is  due  not  only  to  their  scarcity  in  number, 
but  also  to  the  fact  that  the  specific  microorganisms  are  sometimes 
atypical  in  their  morphology  and  staining  properties  in  long-stand- 
ing chronic  cases.  The  demonstration  of  the  gonococcus  is  useless 
so  far  as  the  diagnosis  of  an  endometritis  is  concerned,  as  the  mi- 
croorganisms may  have  come  from  the  cervix,  as  a  result  of  an  ad- 
mixture of  secretion  from  that  locality.  This,  of  course,  does  not 
apply  to  secretions  obtained  directly  from  the  uterine  cavity,  but 
as  the  dangers  of  indiscriminate  intra-uterine  manipulations  are  so 
great,  this  test  is  of  little  practical  value. 

As  a  result  of  chronic  gonorrheal  endometritis  menstrual  disturb- 
ances, such  as  amenorrhea,  menorrhagia,  and  metrorrhagia,  are  not 
infrequent.  Irregularities  as  to  date  of  the  appearance  of  the  flow 
and  profuse  menstruation  are  the  most  frequent  manifestations. 
Dysmenorrhea  is  a  common  symptom  and  is  usually  of  the  conges- 
tive type,  persisting  throughout  the  first  few  days  of  menstrua- 
tion. Occurring  in  women  in  whom  menstruation  has  previously 
been  painless,  and  in  the  absence  of  other  gross  lesions,  and  espe- 
cially if  gonorrhea  of  other  portions  of  the  genital  tract  exists,  dys- 
menorrhea is  a  most  suggestive  symptom.  Gonorrheal  endometritis 
produces  sterility,  but  exceptions  to  this  rule  are  not  infrequent. 
In  those  cases  in  which  impregnation  does  take  place,  abortion 
often  results.  A  pelvic  examination  of  these  cases  reveals  evidences 
of  gonorrhea  in  the  external  genitalia  or  cervix,  and  in  some  cases, 
also,  a  slight  enlargement  and  softening  of  the  uterus  may  be  de- 
tected. The  enlargement  and  change  in  consistence  of  the  uterus  are 
dependent  upon  the  degree  of  metritis  that  accompanies  the  endo- 
metritis, and  are  not  usually  sufficiently  pronounced  to  be  of  much 
practical  value  as  a  diagnostic  sign. 

Diagnosis. — As  will  be  observed  from  a  review  of  the  symptoms, 
the  diagnosis  of  chronic  gonorrheal  endometritis  is  not  easily  made, 
the  chief  difficulty  lying  in  differentiating  between  a  cervical  gonorrhea 
and  a  cervicitis  combined  with  an  endometritis.  In  attempting  the 
differentiation,  the  frequency  of  cervical  infection  and  the  relative 
infrequency  of  cervicitis  combined  with  endometritis  without  adnexal 

'  Adlor  and  Hitschinann:   Monats.  f.  Geb.  ii.  Gyn.,  vol.  xxvii,  No.  1. 

-  Norris,  C.  C,  and  Keene,  F.:  Surg.,  Gyn.,  and  Oli.st.,  January,  1909,  p.  44. 


GONORRHEAL    ENDOMETRITIS  239 

involvement,  should  be  borne  in  mind.  When  chronic  gonorrheal 
endometritis  is  present,  it  is  often  associated  with  inflammations  of 
the  tubes,  and  only  by  careful  pelvic  examination  can  these  complica- 
tions be  excluded. 

Treatment. — Excessive  exercise  should  be  interdicted,  and  in 
some  cases  a  course  of  treatment  while  the  patient  is  confined  to  bed 
will  be  found  beneficial.  Rest  should  be  especially  enjoined  for  a  few 
days  previous  to,  during,  and  following  the  menstrual  period,  for,  as 
has  been  stated,  it  is  at  this  time  that  exacerbations  and  extension 
of  the  infection  are  especially  likely  to  take  place.  The  bowels  should 
be  regulated,  and  a  nutritious  and  easily  assimilated  diet  prescribed. 
If  the  patient  is  anemic,  iron  is  indicated,  and  in  debilitated  subjects 
an  endeavor  should  be  made  to  build  up  the  general  health.  Hot 
sitz-baths  of  salt  water,  given  at  night,  are  often  of  benefit,  and  are 
especially  valuable  in  relieving  the  congestive  pelvic  pain  that  fre- 
quently precedes  menstruation.  Webster^  recommends  counter- 
irritation  by  means  of  blisters  over  the  iliac  regions.  As  regards  local 
treatment,  opinions  vary  widely.  Formerly,  intra-uterine  applica- 
tions were  generally  employed  in  office  practice,  and  undoubtedly 
in  many  cases  resulted  in  spreading  the  disease.  Not  only  is  there 
danger  of  mistaking  a  gonorrheal  cervicitis  for  an  endometritis  and 
thus  carrying  infection  to  a  previously  normal  uterine  cavity,  but 
even  if  the  diagnosis  is  correct,  there  is  considerable  danger  of  caus- 
ing an  extension  of  the  disease  to  the  tubes.  Another  objection 
that  may  be  made  to  this  treatment  is  that  a  preexisting  salpingitis 
may  be  overlooked  and  an  acute  attack  of  pelvic  p(>ritonitis  thus  pre- 
cipitated. 

In  a  small  proportion  of  jiaticnts  the  diagnosis  of  certain  types 
of  tubal  lesions  is  extremely  difficult,  if  not  impossible,  without  the 
aid  of  an  anesthetic.  This  proportion  is  doubtless  small,  but  in  the 
treatment  of  a  large  series  of  cases  it  constitutes  a  very  grave  objection 
to  the  ordinary  routine  method  of  making  intra-uterine  applications 
as  gene-rally  performed  in  office  practice.  Such  intra-uterine  applica- 
tions are  painful  and  do  no  good.  Emmet  was  one  of  the  pionc(>rs  in 
pointing  out  the  limited  field  of  usefulness  of  intra-uterine  applica- 
tions as  generally  made.  For  these  reasons,  therefore,  the  author 
considers  that  intra-uterine  applications  or  manipulations  should 
not  be  performed  in  these  cases  unless  the  technic  demanded  by  a 
major  vaginal  operation  can  be  strictly  carried  out.  This  is  usually 
impossible  in  oflice  treatment  and  without  the  aid  of  an  anesthetic. 
If,  after  a  course  of  hot  fomentations  and  vaginal  (h)uches  extending 
over  a  jjcriod  of  at  least  six  weeks,  together  with  the  local  treatment 
'  Wi'listcr;  Diseases  of  VVomcn. 


240  GONORRHEA    IN    WOMEN 

already  indicated  for  gonorrhea  of  the  cervix,  the  symptoms  still 
point  to  an  intra-utcrine  infection  and  show  no  signs  of  abating,  the 
patient  should  be  anesthetized  and,  after  a  careful  pelvic  examination 
has  been  made  to  exclude  the  possibility  of  adnexal  complications, 
a  thorough  dilatation  and  curetage  of  the  uterus  and  cervix,  under 
strict  antiseptic  and  aseptic  precautions,  should  be  performed.  The 
cervix  should  be  widely  dilated  in  order  to  facilitate  the  intra-uterine 
manipulations.  The  endometrium  of  the  sides  of  the  uterus,  should 
be  removed  with  a  small  Sims  sharp  curet,  followed  by  a  Recamier 
curet  for  the  fundus  and  the  portions  about  the  tubal  openings.  The 
curetage  should  be  done  thoroughly  and  systematically,  and  every  ef- 
fort made  to  remove  as  much  of  the  mucosa  as  possible.  Clark  has 
shown  that  it  is  impossible  to  scrape  away  the  entire  endometrium,  es- 
pecially that  situated  in  the  tubal  angles  and  the  deeper  portions  of  the 
glands  which  sometimes  penetrate  the  uterine  musculature.  Never- 
theless, the  gonococcus,  being  chiefly  a  surface  microorganism,  dezymo- 
tization  of  the  uterine  cavity  can  be  accomplished  in  large  measure. 
Following  the  curetage  the  uterine  cavity  should  be  wiped  dry  with 
strips  of  gauze.  This  will  remove  anj^  debris  that  may  have  been 
left  in  the  uterine  cavity.  It  is  not  advisalsle  to  employ  irrigation 
because  of  the  danger  of  washing  microorganisms  from  the  uterine 
cavity  into  the  tubes  and  thus  spreading  the  infection.  This  is 
especially  likely  to  occur  in  puerperal  cases,  or  in  those  in  which  a 
metritis  is  present.  Under  such  circumstances  the  uterine  ostia  of 
the  Fallopian  tubes  may  be  relaxed  in  the  general  muscular  relaxation 
of  the  uterus.  The  uterine  cavity  should  then  be  painted  with  a 
strong  solution  of  one  of  the  antiblennorrhagics.  For  this  purpose 
perhaps  the  best  is  the  tincture  of  iodin.  Polak  strongly  recommends 
iodin  for  all  gonorrheal  conditions,  and  in  the  author's  hands  it  has 
given  excellent  results.  It  is  important  to  have  the  tissue  as  dry  as 
possible  before  applying  the  iodin.  A  strip  of  gauze  saturated  with 
the  medicament  should  then  be  inserted  into  the  uterine  cavity  and 
left  in  place  for  six  hours.  Bovee^  states  that  curetage  may  be  per- 
formed with  impunity  if  thorough  application  of  the  full  strength  of 
tincture  of  iodin  is  applied  efficiently  and  promptly  to  the  endometrium, 
avoiding  too  much  dilution  by  blood  and  serum.  The  danger  of  light-  \ 
ing  up  the  latent  infection  in  the  endometrium  by  the  curetage  and  I 
iodinization  and  thereby  subjecting  the  previously  healthy  tubes  to  the  I 
danger  of  infection  is  practically  nil.  Unless  followed  by  the  applica- 
tion of  a  gonococcid,  curetage  should  never  be  performed.  Boldt^- 
prefers  to  irrigate  the  uterus  after  the  curetage,  and  follows  this  h-;m 

'  Bovee,  J.  W.:  Amer.  Jour.  Obst.,  July,  1911,  p.  101. 

■  Boldt:  Jour.  Amer.  Med.  Assoc,  February  1,  1908,  p.  332. 


GONORRHEAL    ENDOMETRITIS  241 

packing  the  uterine  cavity  with  gauze  saturated  with  protargol  solution. 
He  removes  the  gauze  in  twentj^-four  hours  and  repeats  the  irrigation 
and  tamponade  on  the  third  day.  This  is  said  not  to  cause  much  in- 
convenience to  the  patient  if  the  cervical  dilatation  has  been  sufficiently 
effectual.  Tweedy^  follows  the  curetage  by  the  application  of  33  per 
cent,  formahn  solution,  and  leaves  a  gauze  drain  saturated  in  this 
solution  in  the  uterine  cavity  for  twenty-four  hours.  Prowe-  follows 
the  curetage  by  uterine  tamponade  of  gauze  soaked  in  pure  ichthyol. 
Other  authorities  prefer  applications  of  strong  solution  of  silver  nitrate 
or  even  pure  phenol.  If  the  latter  is  employed,  its  use  should  im- 
mediately be  followed  by  an  application  of  95  per  cent,  alcohol. 
Following  the  operation  the  patient  should  be  kept  in  bed  for  a  week. 
For  the  first  twenty-four  hours  it  is  preferable,  for  purposes  of  drain- 
age, to  have  the  patient  in  the  Fowler  position.  Subsequently  this 
posture  should  be  assumed  for  one-half  hour  three  or  four  times  daily. 
Twenty-four  hours  after  removal  of  the  uterine  gauze  vaginal  irriga- 
tions of  some  weak  antiseptic  solution,  such  as  the  A.  B.  C.  douche, 
should  be  given  and  repeated  two  or  three  times  daily.  On  the  second 
and  third  day  following  the  operation  the  discharge  is  usually  profuse. 
After  each  defecation  or  urination  the  external  genitalia  should  be 
irrigated  with  an  antiseptic  solution,  and  the  vulva  should  be  pro- 
tected by  sterile  pads  as  long  as  the  patient  remains  in  bed  or  the 
discharge  continues.  Litiuid  food  should  be  given  for  the  first  twenty- 
four  hours  following  the  operation,  after  which  time  a  rapid  return 
to  full  diet  may  be  made.  Little  morbidity  attends  the  operation  of 
curetage  if  it  is  performed  under  proper  aseptic  conditions.  The 
'  chief  danger  is  the  risk  of  setting  up  of  a  pelvic  peritonitis  through  an 
extension  of  inflammation.  When  this  occurs,  it  is  usually  the  result 
of  a  preexisting  adnexal  lesion  that  has  been  overlooked.  When 
the  cervix  is  badly  diseased  and  in  cases  that  have  resisted  palliative 
treatment,  the  curetage  may  be  combined  with  a  trachelectomy.  In 
all  cases  the  curetage  should  include  a  thorough  scraping  of  tlie  cer- 
vical canal  with  a  sharji  curet  of  the  Volkmann  type,  and  the  free 
application  of  the  germicidal  solution  to  this  area.  It  is  hardly 
necessary  to  state  that  before  the  introduction  of  strong  antiseptic 
solutions  into  the  uterine  cavity  the  vagina  should  he  carefully  pro- 
tected by  gauze  or  sterile  vaselin.  .V  time — four  to  five  days — be- 
fore an  expected  menstrual  period  should  be  selected  for  the  curetage, 
as  at  this  period  the  endometrium  is  thicker  and  softer  and  can  be 
more  thoroughly  removed. 

'  Twee<ly:  Brit.  .Med.  .Four.,  vol.  ii,  p.  lO'JS. 

U'rowc:    IJcrliii.  kliii.  WcMlii'ii.sclir.,  NovciiiIkt  11,  I'JlO. 


242  GONORRHEA    IN    WOMEN 

The  dangers  of  curetage  in  those  cases  comphcated  bj^  tubal 
or  adnexal  lesions  have  previously  been  dwelt  upon.  This,  how- 
ever, does  not  apply  to  uterine  treatments  that  are  performed  in 
conjunction  with  operations  on  the  appendages.  The  after-treat- 
ment of  cases  in  which  curetage  has  been  performed  should  consist 
of  cleansing  douches,  and  for  a  period  of  at  least  one  month  only 
the  mildest  forms  of  exercise  should  be  indulged  in.  IVIenstruation 
is  often  somewhat  irregular  and  profuse  for  one  or  two  periods  fol- 
lowing the  operation,  and  patients  should  remain  in  bed  as  long  as 
the  flow  continues.  For  the  treatment  of  menorrhagia  Boldt^  recom- 
mends the  internal  administration  of  cotarnin  hydrochlorid,  given 
in  doses  of  three  grains,  in  gelatin  capsules,  three  times  daily.  Ergot, 
hydrastin,  and  viburnum  prunifolium,  or  combinations  of  the  three 
drugs,  may  also  be  employed.  Douching  should  be  omitted  during 
menstruation.  Coitus  should  not  be  indulged  in  until  the  disease 
has  been  eradicated,  and  precautionary  measures,  such  as  have  been 
recommended  in  the  treatment  of  gonori-hea  of  the  external  genitalia, 
should  be  instituted. 

When  the  plan  of  treatment  just  outlined  fails  to  effect  a  cure 
and  it  is  certain  that  an  endometritis  exists,  it  may  be  found  advisable 
to  repeat  the  operation.  This  should  not,  however,  be  done  until  at 
least  three  months  have  been  allowed  to  elapse.  The  histologic 
examination  of  the  curetings  obtained  at  the  first  operation  will  afford 
confirmatory  evidence  of  a  previously  existing  endometritis.  The 
demonstratioij  of  gonococci  in  the  endometrium  in  chronic  cases 
of  gonorrheal  endometritis  is  difficult,  and  little  importance  can  be 
attached  to  negative  findings.  In  a  few  cases,  after  the  operation, 
more  or  less  profuse  uterine  bleeding  and  other  sjmiptoms  of  en- 
dometritis will  persist,  despite  the  treatment  just  descril^ed.  In 
these  cases,  if  the  cervical  canal  is  already  dilated,  intra-uterine 
applications,  performed  under  the  strictest  aseptic  precautions,  are 
justifial)le  and  sometimes  beneficial.  The  contraindications  to  this 
plan  of  treatment  are  a  history  or  symptoms  pointing  to  inflam- 
matory lesions  of  the  adnexa,  doubt  as  to  the  existence  of  an  en- 
dometritis, or  the  presence  of  a  tightly  contracted  cervical  canal. 
A  period  shortly  after  the  cessation  of  menstruation  should  be  se- 
lected, as  at  this  time  the  endometrium  is  thin  and  applications 
can,  therefore,  be  expected  to  reach  the  deeper  glands  better  than 
at  any  other  time.  The  patients  should  be  placed  in  the  dorsal 
position,  and  the  external  genitalia  and  vagina  thoroughly  scrubbed 
with  tincture  of  green  soap  and  hot  water,  followed  by  a  1 :  2000  bi- 

1  Boldt:  Jour.  Amer.  Med.  Assoc,  February  1,  190S,  p.  332. 


1 


GONORRHEAL  ENDOMETRITIS  243 

chloric!  solution.  If  the  green  soap  and  water  do  not  remove  the 
cervical  mucus,  the  cer\dx  should  be  sprayed  and  swabbed  with  one 
of  the  alkaline  solutions  recommended  in  the  treatment  of  cer\ical 
gonorrhea,  and  the  soap  and  water  again  applied.  The  vagina  should 
now  be  packed  with  gauze  or  cotton  soaked  in  the  bichlorid  solution. 
This  should  be  left  in  place  while  the  operator  makes  the  other  neces- 
sary preparations.  Then,  under  strict  aseptic  precautions,  the  cervix 
should  be  exposed  through  a  large  bivalve  speculum,  and  the  anterior 
lips  grasped  in  a  double  tenaculum.  Cotton  pledgets  or  sterile  vaselin 
are  now  placed  in  the  vagina,  to  protect  it  from  the  action  of  the  anti- 
septic that  is  to  be  employed.  Tlije  applicators,  which  should  have 
been  previoush'  prepared  and  wrapped  with  a  thin  layer  of  sterile 
cotton,  are  now  dipped  in  the  solution  and  applied.  For  this  purpose, 
tincture  of  iodin  is  perhaps  the  most  efficient  drug,  although  formalde- 
hyd  (37-40  per  cent.),  silver  nitrate  (1  dram  to  the  ounce),  pure  ich- 
thyol,  or  pure  phenol  are  preferred  by  some  operators.  The  solu- 
tion should  be  applied  thoroughly  to  all  parts  of  the  uterine  cavity, 
and  especially  to  the  tubal  angles.  If  phenol  is  the  chosen  medica- 
ment, its  use  should  be  followed  by  the  application  of  95  per  cent, 
alcohol.  It  is  necessarj',  as  has  been  stated,  that  the  solution  employed 
reach  all  parts  of  the  uterine  cavity,  and  to  attain  this  end  it  is  ad- 
visable to  prepare  three  or  four  applicators  before  beginning  the 
treatment,  so  that  they  may  be  used  quickly,  one  after  the  other, 
without  the  delay  occasioned  if  only  one  applicator  is  at  hand.  If 
iodin  is  the  antiseptic  selected,  an  excellent  plan  is  to  precede  the 
use  of  the  applicators  by  the  injection  of  a  dram  of  the  solution  by 
means  of  an  intra-uterine  applicating  syringe,  and  follow  this  im- 
mediately by  the  insertion  of  cotton  pledgets  soaked  in  the  same 
solution.  The  applications  cause  considerable  pain,  and  for  this 
reason  it  is  necessary  to  complete  the  treatment  quickly  after  the 
antiseptic  is  once  applied,  or  the  patient  is  likely  to  draw  up  on  the 
table  and  make  the  remainder  of  the  procedure  difficult.  The  treat- 
ment should  be  concluded  by  introducing  a  sterile  vaginal  tampon 
saturated  with  boroglycerol  or  boric-acid  ointment  and  the  applica- 
tion of  a  sterile  vulvar  dressing.  The  pain  caused  by  the  intra-uterine 
application,  as  outlined  above,  lasts  for  but  a  few  hours,  and  if  un- 
usually severe,  may  be  alleviated  by  the  administration  of  an  anodyne. 
If  the  patient  is  of  a  nervous  temperament,  the  pain  may  be  tempo- 
rarily relieved  and  the  application  facihtated  by  cocainizing  the  uterine 
cavity  prior  to  the  application. 

The  patient  should  remain  quiet  for  three  or  four  days  following 
the  troatnicut.     She  should   be  warned  that   the  vaginal  discharge 


244  GONORRHEA    IN   WOMEN 

will  probably  be  temporarily  increased.  As  has  previously  been 
stated,  it  is  important  that  husbands  of  such  patients  be  made  ac- 
quainted with  the  dangers  of  reinfection,  and  that  cohabitation  be 
interdicted  until  both  husband  and  wife  are  absolutely  cured.  If 
it  is  found  impossible  to  attain  this  end,  precautionary  measures 
should  be  adopted,  and  coitus  enjoined  for  at  least  a  week  following 
the  cessation  of  menstruation.  For  these  cases,  Dudley^  has  sug- 
gested an  ingenious  form  of  treatment.  The  device  used  is  a  tupelo 
sponge  or  sea-tangle  tent,  over  the  distal  end  of  which  has  been  at- 
tached half  a  gelatin  capsule  filled  with  whatever  medicament  may  be 
selected  for  intra-uterine  application.  For  cases  of  endometritis  or 
metritis  this  observer  recommends  a  powder  consisting  of  one  part 
of  iodin  crystals  and  two  parts  of  potassium  iodid,  this  being  a  pro- 
portion that  dissolves  readily  in  water.  From  two  to  four  grains 
of  this  mixture  are  introduced  at  each  treatment.  The  tent  is  steril- 
ized by  dry  heat,  and  the  gelatin  capsule  by  the  iodin,  which  is  al- 
lowed to  remain  in  the  capsule  for  two  days  before  it  is  used.  The 
technic  of  the  application  is  as  follows:  The  vagina  and  external 
genitalia  are  cleansed  as  for  an  ordinary  plastic  operation.  No  general 
anesthetic  is  required.  An  applicator  saturated  with  a  10  per  cent, 
solution  of  cocain  is  introduced  into  the  uterus  and  allowed  to  re- 
main in  place  for  ten  minutes.  The  cervix  is  then  carefully  dilated 
with  a  small  Goodell  dilator  and  the  tent  introduced.  In  about 
twelve  hours  the  tent  is  removed,  and,  if  it  is  thought  advisable,  a  larger 
one  may  now  be  inserted.  The  advantages  claimed  for  this  method 
of  treatment  are  that  good  dilatation  is  secured  and  the  medication 
is  applied  to  the  endometrium  for  a  prolonged  period.  Dudley  rec- 
ommends that  the  treatment  be  carried  out  in  a  hospital. 

Intra-uterine  applications  in  office  practice  have  a  limited  field 
of  usefulness,  and  the  benefits  to  be  derived  from  this  plan  of  treat- 
ment are  not,  as  a  rule,  great.  The  author  does  not,  however,  go  so 
far  as  Boldt,^  who  stigmatizes  intra-uterine  treatment  performed  in 
office  practice  as  "tinkering,"  but  believes  that  the  contraindications 
to  such  treatment  should  be  rigidly  adhered  to,  and  that  in  all  cases 
operative  intervention,  of  the  type  described,  will  give  far  better 
results.  Concomitant  gonorrhea  of  the  cervix,  urethra,  or  external 
genitalia  should  receive  appropriate  treatment. 

Vaporization  has  been  employed  by  some  operators  in  the  treat- 
ment of  chronic  gonorrheal  endometritis,  with  good  results.  The 
introduction  of  live  steam  into,  the  uterine  cavity  is  not  without  danger. 

'  Dudley,  E.  C:  Jour.  Amer.  Med.  Assoc.,  June  24,  1911,  p.  1S74. 
^  Boldt:  Jour.  Amer.  Med.  Assoc,  February  1,  190S,  p.  332. 


GONORRHEAL   ENDOMETRITIS  245 

^lany  cases  have  been  reported  in  which  the  uterine  cavity  has  been 
accidentally  obliterated,  or  in  which  adhesions  between  the  anterior 
and  posterior  uterine  walls  have  formed  as  a  result.  It  is  claimed  for 
this  treatment  that  it  is  applicable  to  all  cases;  that  it  is  free  from 
the  danger  of  spreading  infection,  and  that  it  is  more  thorough  than 
curetage  and  the  application  of  germicides.  That  vaporization  is 
free  from  the  danger  of  spreading  infection  has  not  been  proved;  in 
fact,  the  author  believes  that  the  risks  attending  this  plan  of  treatment 
are  quite  as  great  as,  if  not  greater  than,  those  following  curetage;  he 
does  not  beheve  that  the  treatment  is  more  thorough  than  that  al- 
ready described,  as  it  is  self-evident  that  it  is  impossible  to  remove 
all  the  endometrium  without  causing  obliteration  of  the  uterine  cavity. 
One  of  the  chief  disadvantages  to  vaporization  is  the  difficulty  of 
accurately  controlling  the  stream  and  ascertaining  the  exact  depth 
to  which  the  tissues  are  being  destroyed.  The  endometrium  in  these 
cases  varies  quite  markedly  in  thickness,  and  what  would  be  sufficient 
steam  completely  to  boil  off  the  mucosa  in  one  case,  might  only  destroy 
the  superficial  layers  in  another. 

Brindeau'  has  found  the  use  of  cviltures  of  the  lactic-acid  bacillus 
of  great  value  in  various  gj'necologic  conditions  in  which  irritating 
discharges  and  inflammatory  conditions  are  present.  He  has  treated 
by  this  method  14  cases  of  endometritis  and  78  additional  patients 
suffering  from  various  complaints.  In  endometritis  the  treatment 
is  said  quickly  to  overcome  the  offensive  nature  of  the  discharge. 

Adenomyoha  of  the  Uterus  wriH  Chronic  Gonorrheal  Endometritis 
Adenoniyoma  of  the  uterus  is  u  (•omi)aratively  frequent  tumor. 
According  to  the  statistics  from  the  Laboratory  of  Gynecologic  Pathol- 
ogy at  the  University  of  Pennsylvania,  in  a  series  of  395  myomatous 
uteri  this  tumor  has  been  found  24  times,  or  in  6.7  per  cent,  of  all  cases. 
According  to  C'ullcn,-  adenomyomata  are  found  to  constitute  about 
5.7  per  cent,  of  all  myomata.  ("ullen  has  shown  that,  in  a  large  per- 
centage of  cases,  the  tumors  are  an  ingrowth  of  the  normal  eiulonie- 
triuni  into  the  substance  of  either  a  discrete  or  a  diffuse  myomatous 
tuniiir:  fnnii  this  it  would  naturallj'  be  concluded  that  the  endome- 
trium in  the  neoplasms  might  be  subject  to  an  extension  of  inflam- 
mation from  the  uterine  cavity,  a  fact  that  has  been  demonstrated 
in  a  few  instances.  The  reason  that  the  condition  is  not  more  fre- 
quently encountered  is  probably  due  to  the  fact  that  the  gf)nococcus 
is  mainly  a  surface  microc'irganism,  and  that  even  in  ordinary  cases  of 

'  Hriiiilcim;  Arch.  mens,  fl'ohsl.  ct  dc  pyii.,  Miircli,  1!(12. 
'C'lilliii:    AdciininyorriM  of  l[ic  I'liTUs,  l'.H)S,  p.  1. 


246  GONORRHEA   IN   WOMEN 

endometritis  the  superficial  portions  of  the  mucosa  are  the  areas 
chiefly  involved.  It  would,  therefore,  follow  as  a  matter  of  course 
that  the  deeper  portions  of  the  long  glands  and  their  surrounding 
stroma,  which  have  grown  far  into  the  myomatous  tissue,  would  be 
even  less  frequently  diseased.  Another  factor  that  plays  a  part  in 
the  protection  of  adenomyoma  from  gonorrheal  infection  is  that  many 
of  the  glands  in  the  tumor  substance  have  been  partially  or  completely 
cut  off  from  the  endometrial  cavity  by  the  constriction  caused  by  the 
growth  of  the  neoplasm,  and  are  thus  isolated  from  the  source  of  the 
infection.  Of  the  24  cases  of  adenomyoma  examined  by  the  author, 
7  were  associated  with  endometritis,  and  in  only  1  of  these  were  in- 
flammatory changes  at  all  marked  in  the  endometrial  tissue  of  the 
tumor.  All  7  cases  of  endometritis  were  accompanied  Isy  inflamma- 
tory lesions  of  the  appendages.  In  the  one  specimen  a  moderate  de- 
gree of  inflammatory  reaction  was  present  in  the  mj^omatous  tissue 
adjacent  to  the  glands.     The  adenomyoma  was  of  the  diffuse  t3^pe. 

The  symptoms  of  endometritis  occurring  in  and  with  an  adenomy- 
oma of  the  uterus  are  those  of  uncomplicated  adenomyoma  of  this 
organ,  superimposed  upon  which  are  the  evidences  of  an  endometritis, 
as  previously  described.  Beyond  the  diagnosis  of  an  endometritis 
complicating  a  myomatous  tumor  of  the  uterus,  probably  adenomatous 
in  character,  a  definite  distinction  as  to  the  type  of  lesion  present  is 
impossible  before  the  neoplasm  has  been  subjected  to  a  histologic 
examination.  The  treatment  is,  of  course,  operative,  and  should 
depend  largely  upon  the  individual  case. 

GONORRHEAL  METRITIS 
Inflammation  of  the  uterine  musculatiu'e  may  be  either  acute  or 
chronic  in  character.  The  condition  may  be  general,  invoh'ing  the 
entire  uterus,  or  may  be  localized  to  certain  portions,  as  in  the  case  of 
abscess  formation.  (Owing  to  the  diversity  in  symptoms  and  to  the 
rarity  of  the  lesion,  intramural  uterine  abscesses  ^^dll  be  described 
under  a  separate  heading.) 

Acute  Gonorrheal  Metritis 
Acute  gonorrheal  metritis  is  alwaj's  accompanied  bj'  an  endome- 
tritis. If  the  latter  is  severe,  the  underlying  muscular  structures  are 
almost  certain  to  be  involved.  Metritis  is  especially  likely  to  occur 
if  the  endometritis  follow  childbirth  or  miscarriage :  the  soft,  involut- 
ing uterus  offers  little  resistance  to  the  microorganisms,  and  makes  an 
excellent  nidus  for  infection.  Madlener^  was  one  of  the  first  observers 
to  demonstrate  the  gonococcus  in  the  uterine  musculature. 
>  Madleuer,  M.:   Cent.  f.  Gyn.,  1895,  No.  50. 


GONORRHEAL    METRITIS  247 

Symptoms. — These  depend  largely  upon  the  grade  of  infection 
and  the  amount  of  resisting  power  of  the  individual.  In  the  main, 
the  symptoms  are  similar  to  those  accompauA-ing  acute  eiidometritis, 
and  which  have  been  described  elsewhere.  AMien  metritis  is  present, 
the  severity  of  these  symptoms  is  Ukely  to  be  augmented.  The  con- 
stitutional effects  are  more  severe,  and  the  disease  does  not  yield  so 
readily  to  treatment.  The  condition  is  usually  ushered  in  with  a 
chill,  followed  by  nausea,  vomiting,  malaise,  chilliness,  or  headache. 
The  pulse-rate  is  increased,  the  temperature  is  elevated,  the  tongue 
becomes  coated,  the  appetite  is  lost,  and  constipation  is  usuallj^  present, 
although  sometimes  there  is  diarrhea.  If  lactation  is  present,  the 
secretion  of  milk  may  be  diminished  or  abolished.  The  discharge 
is  increased  in  amount,  and  is  frequently  of  a  dark,  chocolate  color, 
owing  to  the  admixture  of  blood,  but  it  may  be  yellow  or  even  whitish. 
The  uterus  is  uniformly  enlarged,  and  is  tender  to  the  touch.  Tender- 
ness of  the  uterus  and  irregular  and  profuse  menstruation  are  usually 
pronounced  symptoms.  Adnexal  complications  are  more  frequent 
than  in  uncompUcated  endometritis.  The  cervix  is  invariably  in- 
volved, and  is  usually  the  seat  of  a  well-marked  cervicitis.  The 
cervical  canal  is  generally  markedly  patulous  and  easily  dilated. 

Diagnosis. — When  acute  gonorrheal  metritis  follows  pregnancy  or 
abortion,  the  condition  must  be  distinguished  from  septic  metritis 
caused  by  the  streptococcus  or  other  pyogenic  microorganisms.  In 
the  latter  type  of  infection  the  symptoms  are,  as  a  rule,  more  severe, 
the  pulse  and  temperature  are  higher,  the  general  constitutional 
symptoms  are  likely  to  be  more  alarming,  and  the  condition  comes  on 
earlier.  In  the  gonorrheal  variety,  on  the  other  hand,  during  the 
first  few  days  following  the  emptying  of  the  uterus  the  gonococci 
multiply  in  the  superficial  layers  of  the  endometrium,  w^hereas  in 
the  deeper  layers  there  is  an  outpouring  of  leukocytes,  forming  a 
protective  barrier  of  resistance.  During  this  period  the  symptoms 
arc  not  pronounced. 

The  diagnosis  of  acute  gonorrheal  metritis  maj'  i)e  made  from  the 
evidences  of  gonorrhea  about  the  external  genitalia,  urethra,  and 
cervix,  and  from  the  bacteriologic  demonstration  of  the  infecting 
micnxirganism  from  these  locations  or  in  the  lochia.  The  diagnosis 
of  gonorrhea  in  the  external  genitalia  does  not,  of  course,  preclude  the 
possibility  of  a  streptococcic  infection  existing  in  the  uterus,  but  is 
strong  presumptive  evidence  of  the  type  of  infection  present.  Further- 
more, the  gonococcus  produces  extension  bj-  way  of  the  mucosa, 
so  that  if  complications  arise,  the  tubes  are  almost  always  affected, 
whereas  if  the  infection  is  due  to  the  streptococcus,  cellulitis  of  the 


248  GONORRHEA    IN   WOMEN 

broad  ligament,  with  its  accompanying  symptoms,  is  often  found. 
In  gonorrheal  metritis,  especially  of  it  follows  the  puerperium,  adnexal 
complications  are  the  rule.  "WTien  following  the  emptying  of  a  preg- 
nant uterus,  gonorrheal  metritis  must  also  be  distinguished  from 
autointoxication  from  the  bowels  and  from  lesions  in  the  breasts,  con- 
ditions that  will  be  more  fully  dealt  with  in  the  chapter  on  Gonorrhea 
in  the  Puerperium. 

Treatment. — This  should  be  similar  to  that  previously  suggested 
for  acute  endometritis.  As  the  constitutional  symptoms  are  likely 
to  be  more  severe,  more  active  general  treatment  is  indicated.  If 
the  uterus  is  large  and  boggy,  the  administration  of  ergot  is  often 
followed  by  good  results,  but  the  drug  should  not  be  employed  if  the 
presence  of  an  abscess  of  the  uterine  parenchyma  is  suspected.  The 
internal  administration  of  atropin  is  said  by  Schindler^  to  be  beneficial 
as  a  prophylactic  measure  against  the  spread  of  the  infection,  and  may 
be  employed  in  all  acute  gonorrheal  infections  of  the  uterus,  as  de- 
scribed in  a  previous  chapter.  The  drug  is  given  in  the  ordinary 
therapeutic  doses.  Pollock  and  Harrison-  also  report  good  results 
following  the  use  of  this  drug.  The  patient  should  be  kept  in  the 
Fowler  position,  to  favor  drainage  of  the  uterine  cavity.  Local 
measures,  as  previously  suggested  for  the  treatment  of  acute  endome- 
tritis, should  be  adopted. 

Chronic  Gonorrheal  METRrris 

This  condition  is  always  preceded  by  an  endometritis.  In  some 
cases  resolution  may  have  taken  place  in  the  mucosa,  and  when  such 
specimens  are  examined,  the  latter  may  appear  to  be  comparatively 
normal,  whereas  the  inflammation  of  the  underlying  musculature 
still  remains.  Chronic  gonorrheal  metritis  may  follow  in  the  wake  of 
an  acute  attack,  or  may  be  subacute  from  the  beginning.  The  extent 
of  the  involvement  of  the  uterine  musculature  varies  widely  in  dif- 
ferent cases.  Thus  in  some  patients  only  a  slight  subendometrial 
inflammation  will  be  present,  whereas  in  others  the  uterus  may  be 
found  markedly  enlarged,  the  chief  pathologic  lesion  being  very  evi- 
dently in  the  uterine  musculature. 

Symptoms. — These  are  in  general  similar  to  those  of  chronic 
endometritis,  but  they  are,  as  a  rule,  more  pronounced.  Theilhaber 
and  Meir'  believe  that  in  many  cases  the  leukorrhea  and  uterine  hem- 
orrhages that  are  said  to  result  from  an  endometritis  are  in  reality 

'  Schindler,  C:  Arch.  f.  Gyn.,  Berlin,  1909,  vol.  Ixxxvii,  p.  607. 

2  Pollock,  C.  E.,  and  Harrison,  L.  H.:  Gonococcal  Infections,  London,  1912,  p.  122. 

'  Thoilhaber  and  Meir:  .\rch.  f.  Gyn.,  vol.  Ixvi,  No.  1,  p.  1. 


i 


GONORRHEAL   METRITIS  249 

caused  by  lesions  in  the  myometrium,  and  that  metritis  is  more  fre- 
quent than  is  generally  beheved.  On  pelvic  examination  of  cases  of 
metritis  the  uterus  is  found  to  be  symmetrically  enlarged  and  more 
or  less  tender  on  palpation.  Both  the  enlargement  and  the  tenderness 
are  generally  less  marked  than  in  the  acute  condition.  According 
to  Bell,'  the  muscular  walls  of  the  uterus,  when  infected  during  the 
puerperium,  become  bulky  and  haid  (chronic  "fibrotic"  metritis). 

Treatment. — This  is  similar  to  that  suggested  for  chronic  endome- 
tritis. For  intra-uterine  applications  after  curetage  Diaz-  and  Web- 
ster'' strongh'  recommend  formalin.  The  author,  however,  prefers 
the  tincture  of  iodin.  If,  after  two  or  more  curetments,  the  symptoms 
still  continue  to  be  severe,  and  especialh^  if  the  uterine  hemorrhages 
are  intractable,  a  supravaginal  hysterectomy  and  bilateral  salpingec- 
tomy maj'  become  necessary.  The  plan  suggested  by  Kell}',  of  ex- 
cising from  the  fundus  a  V-shaped  portion  of  the  uterine  wall, 
including  the  endometrium,  may  be  advisable  in  some  cases  in 
which  the  appendages  are  normal  and  the  patient  is  especially  desirous 
of  maternity,  although  the  probability  of  the  latter  taking  place  is 
small.  The  chief  advantage  offered  by  this  partial  hysterectomj'  is 
that  menstruation  is  not  abolished.  Kelly  reports  good  results  fol- 
lowing this  method. 

Jayle  and  Loewy^  have  employed  Bier's  method  of  hyperemia  in 
a  number  of  cases,  with  satisfactory  results.  These  authors  have 
devised  a  glass  tube  with  a  syringe  attached  that  aspirates  when  the 
piston  is  pushed  into  the  cylinder,  and  thus  creates  a  vacuum.  This 
enables  them  to  dispense  with  assistance,  which  otherwise  would  be 
necessary,  the  cupping-glass  being  held  in  one  hand  and  the  asjiirator 
in  the  other.  Each  treatment  lasts  for  about  five  minutes.  The 
sittings  are  held  daily,  the  number  being  regulated  by  the  reaction 
elicited  and  the  effect  produced  on  the  disease.  The  first  application 
of  Bier's  cupping-glass  to  the  cervix  causes  very  decided  pain  in  the 
pelvis  and  sacral  regions,  sometimes  radiating  to  the  thighs,  but  aft(>r 
a  few  treatments  this  pain  disappears. 

In  those  cases  of  metritis  complicated  bj'  intractable  uterine 
hemorrhages  vaj^orization  luis  been  suggested  as  a  means  of  either 
destroying  the  endometrium,  or  in  severe  cases  of  actually  obliter- 
ating the  uterine  cavity.  In  the  former  event  the  operation  offers 
no   advantages    over    curetage,    as    previously    described.     As    has 

'  Ucll,  \V.  H  :    l'iiiiii|)l<>sof  (lynccolopy,  1910. 

'  Diaz:  .ViinalfStio  lu  .\cii<i.  deObstet.,  etc.,  .Madrid,  HIIO,  vol.  iii,  p.  03. 

'  UVbstpr:   Di.se!i,se.s  of  Wonu'n. 

•Jayle,  I'".,    and  I.ocwv,  K.:    Vrrsao  mM.,  Paris,  l!ll)7,  vol.  xv,  p.  SVA. 


250  GONORRHEA    IN    WOMEN 

been  indicated,  the  difficulty  of  accurately  controlling  the  stream 
within  the  uterine  cavity  is  the  chief  obstacle  to  successful  treat- 
ment by  this  method.  We  have  no  means  at  our  command,  unless 
the  curat  is  employed,  of  determining  the  actual  thickness  of  the 
endometrium.  Therefore  the  amount  of  steam  necessary  to  destroy 
one  endometrium,  might  in  another  case  be  sufficient  to  remove  all 
the  mucosa  and  a  part  of  the  underlying  muscle,  and  result  in  ob- 
literation of  the  uterine  cavity  in  an  organ  in  which  the  lining 
membrane  was  thin,  or  might  not  remove  sufficient  tissue  if  the 
endometrium  was  greatly  hypertrophied.  Vaporization  as  a  means 
of  obliterating  the  endometrial  cavity  is  justifiable  only  at  the 
menopause,  and  even  then,  in  the  author's  opinion,  is  inferior  to 
hysterectomy,  over  which  it  offers  no  advantages,  and  the  likelihood 
of  such  uteri  subsequently  producing  distressing  symptoms  is  very 
considerable.  If  even  the  intramural  tubal  mucosa  is  infected,  vapor- 
ization offers  no  hope  of  cure.  Flatau,'  at  a  meeting  of  the  Franconian 
Obstetrical  Society,  declared  that  from  his  own  ten  years'  experience, 
and  from  that  of  others,  the  cases  in  which  vaporization  was  justi- 
fiable before  the  menopause  must  be  most  exceptional.  The  same 
author  further  stated  that  vaporization  should  be  used  only  when 
the  strongest  indications  exist,  and  that  the  absolute  obliteration  of 
the  uterine  cavity  cannot  be  insured  without  the  employment  of  the 
soundest  technic.  On  the  other  hand,  Frankenstein-  reports  that  he 
has  applied  vaporization  192  times  in  the  Kiel  Frauen-Klinik  under 
Werth,  for  various  conditions,  with  good  pfimary  results.  He  states, 
however,  that  in  young  patients,  vaporization  is  not  justifiable  except 
under  very  exceptional  circumstances.  He  believes  that  with  carefully 
considered  indications  and  accurate  technic  vaporization  may  be  em- 
ployed successfully  in  the  treatment  of  hemorrhages  at  the  climacteric. 
Gellhorn,^  Polano,*  Horrmann,^  Lewicki,**  StSckel,'  Jung,^  Eltze,' 
Wagner,'"  Hasenfeld,''  Fett,'-  Peham  and  Keitler,'^  Keilmann,'*  and 

1  Flatau,  S.:  Samml.  klin.  Vortr.,  Leipzig,  1910,  n.  f.  No.  585. 

-  Frankenstein:   Monats.  f.  Geb.  u.  Gyn.,  No.  2,  p.  102. 

'  Gellhorn,  G.:  Amer.  Jour.  Obstet.,  1909,  vol.  Ix,  No.  1. 

•■  Polano:  Zentralbl.  f.  Gyn.,  1901,  No.  30. 

=  Horrmann:  Monats.  f.  Geb.  u.  Gyn.,  1907. 

'  Lewioki:  Zentralbl.  f.  Gyn.,  1906,  No.  7,  abstract. 

'Stockel:  /bid.,  1905,  No.  48.  Mung:  Miinoh.  med.  Wochenschr.,  1905,  No.  52. 

"  Eltze:  Zentralbl.  f.  Gyn.,  1907,  p.  1602. 

•"  Wagner:  Naturforscherversammlung,  Dresden,  1907. 

"  Hasenfeld:  Wien.  klin.  Wochenschr.,  1907,  No.  18. 

'«  Fett:  Monats.  f.  Geb.  u.  Gyn.,  1905,  p.  674. 

"  Peham,  H.,  and  Keitler,  H.:  Beit.  z.  Geb.  u.  Gyn.;   Rudolf  Chrobak,  1903,  p.  626. 

"  Keilmann:  St.  Petersburg,  med.  Wochenschr.,  1904,  No.  28. 


I 


GONORRHEAL   METRITIS  251 

manj^  others  have  employed  dry  heat  for  cases  of  metritis.  This 
form  of  treatment  is  claimed  to  be  especially  beneficial  in  those  cases 
that  are  accompanied  by  exudative  processes  within  the  pelvis.  The 
presence  of  adnexal  lesions  do  not  contraindicate  this  treatment;  it 
should,  however,  be  employed  only  in  chronic  cases,  and  in  those  in 
which  the  temperature  and  pulse  are  normal.  The  treatments  should 
always  be  administered  under  the  control  of  a  physician.  Gellhorn^ 
has  devised  an  excellent  apparatus  for  the  application  of  the  hot  air. 
This  instrument  is  a  modification  of  Kehrer's"  apparatus,  and  con- 
sists of  two  semicircular  cradles  made  of  thin  sheet-iron,  and  covered 
on  the  inside  with  asbestos.  These  two  cradles  lie  one  upon  the  other, 
and  may  be  pulled  apart  in  the  fashion  of  a  telescope.  On  the  inside 
of  the  free  edges  eight  electric-light  bulbs  are  attached,  and  a  long  wire 
furnishes  the  connection  with  the  nearest  switch.  A  hole  in  the 
roof  of  the  cradle  is  provided  for  the  thermometer.  This  instrument, 
in  Gellhorn's  hands,  has  given  excellent  results.  The  mode  of  applica- 
tion is  as  follows:  The  apparatus,  with  the  thermometer  adjusted, 
is  placed  over  the  exposed  abdomen  and  the  electric  light  turned  on. 
As  it  is  best  to  apply  the  heat  gradually,  the  apparatus  is  not  covered 
with  blankets  for  a  few  minutes.  A  temperature  of  200°  to  220°  F. 
is  usually  employed.  An  ice-bag  or  a  cold  cloth  is  placed  on  the 
patient's  head,  and  she  is  urged  to  drink  large  quantities  of  cool  water. 
In  about  ten  minutes  the  temperature  reaches  180°  F.,  and  some 
patients  will  complain  of  intense  burning.  The'  operator  should  be 
guided  bj-  the  sensation  of  the  patients,  and  should  discontinue  the 
treatment  if  it  causes  much  discomfort.  As  the  treatments  advance, 
higher  temperatures  can  usually  be  borne.  All  observers  state  that 
pain  rapidly  decreases,  and  a  complete  cessation  of  discomfort  occurs 
after  four  or  five  treatments.  In  a  certain  proportion  of  cases  there 
is  only  subjective  improvement,  but  in  the  vast  majority  a  diminution 
in  the  size  of  the  exudate  rapidly  takes  place.  Polano'  saw  an  old 
exudate  of  stony  consistence,  extending  laterally  to  the  right  iliac 
bone,  and  upward  to  the  umbilicus,  disappear  completely  after  20 
treatments.  In  one  of  Burger's'  cases  a  tumor  reaching  as  high  as  the 
umbilicus  was  reduced  by  18  treatments  to  a  single  cord  the  size  of 
the  finger.  Keilnumn^  reports  50  cases;  Peham  and  Keitler,"  120 
cases,  and  Fett,"  88  cases,  the  great  majority  of  which  were  greatly 
improved  or  cured  by  this  treatment.     Sixty-five  per  cent,  of  Fett's" 

'  (icllliorii:   Loc.cit.  Mvulircr:   Zcntnill>l.  f.  Cyn..  I'.IOl,  N'o.  52. 

"  I'ohmo:  (Quoted  by  Gellhorn:  Loc.cit.         *  Burger:  (Juoti'd  by  ( lellhorn:   Loc.cil. 
'  Keilmann:  Loc.  cil.  *  IVham  ami  Kciller:  Loc.  cii. 

'  Felt:  .Moiiats.  f.  Gt-b.  u.  Gyn.,  1905,  p.  ()74.  «  Fell:  Loc.  cit. 


252  GONORRHEA    IN    WOMEN 

patients  were  cured,  7  per  cent,  improved,  and  15  per  cent,  unim- 
proved. Of  Peham  and  Keitler's^  cases,  58  per  cent,  were  entirely 
cured,  and  20  subsequently  became  pregnant.  Treatments  should 
be  discontinued  if  an  exacerbation  of  the  inflammation  occurs. 

In  cases  in  which  exudative  processes  are  a  marked  feature  Kirsten- 
advocates  the  injection,  into  the  exudate,  of  normal  salt  solution,  to 
promote  its  absorption.  He  has  employed  this  treatment  in  three 
cases  with  good  results,  but,  as  he  himself  observes,  the  patients  might 
have  recovered  as  promptly  if  he  had  not  resorted  to  this  treatment. 
Mocquot  and  Mock^  recommend  the  injection  of  30  to  40  per  cent, 
solution  of  zinc  chlorid.  As  the  injections  are  painful,  a  preliminary 
injection  of  a  5  per  cent,  solution  of  cocain  or  novocain  is  advised. 
They  report  excellent  results.  The  author  has  had  no  experience 
with  this  form  of  treatment,  which  is  advocated  by  so  many  French 
surgeons.  The  injection  of  a  more  or  less  toxic  solution  into  the  base 
of  the  broad  ligaments,  or  even  into  the  parametrium,  does  not  seem 
a  sound  mode  of  treatment,  and  it  would  appear  that  the  patients 
recover  despite,  rather  than  because  of,  the  injections. 

GONORRHEAL  INTRAMURAL  ABSCESS  OF  THE  UTERUS 
Gonorrheal  intramural  abscess  of  the  uterus  is  an  extremely  rare 
condition.  This  may  be  explained  by  the  fact  that,  as  has  been  stated, 
the  gonococcus  is  mainly  a  surface  microorganism,  and  therefore  does 
not  usually  obtain  access  to  the  uterine  parenchyma.  In  1892  von 
Franque,^  in  an  excellent  monograph,  reported  15  authentic  cases  of 
intramural  abscess.  The  bacteriologic  cause  was  not  satisfactorily 
demonstrated  in  all  cases,  but  7  of  them  were  dependent  for  their 
origin  upon  an  infection  following  childbirth,  so  that  it  seems  fair  to 
assume  that  only  the  minority  of  these  were  gonococcal  in  origin. 
Five  years  later  Noble"  briefly  reported  4  cases  of  abscess  of  the  puer- 
peral uterus,  making  in  all  8  that  had  occurred  in  his  practice.  He  also 
reviewed  11  other  cases  collected  from  the  literature.  The  following 
year  Mercade^  reviewed  the  literature  on  this  subject,  and  was  able 
to  find  41  authentic  cases,  of  which  22  followed  parturition,  whereas 
in  a  recent  paper  Risch^  reviews  22  cases.     Beyer*  reports  the  history 

'  Peham  and  Keitler:   Beit.  z.  Geb.  u.  Gyn.,  190:3,  p.  026. 

=  Kirsten:  Zent.  f.  Gyn.,  December  25,  1909. 

'  Mocquot  and  Mock:  Rev.  de  Chir.,  1912,  No.  5,  p.  779. 

■*  von  Franque:  Samml.  klin.  Vortrage,  new  series,  No.  .316. 

^  Noble:  Trans.  Amer.  Gyn.  Soc,  1906,  vol.  xxxi,p.  296. 

^  Mercade:  Annal.  de  Gyn.  et  d'Obstet.,  1907,  second  series,  vol.  iv,  p.  29. 

'Risoh:   Medizinische  Klinik,  1911,  No.  5. 

»  Heyer:  JNIonats.  f.  Geb.  u.  Gyn.,  vol.  x.xxi.  No.  4. 


I 


GONORRHEAL    INTRAMURAL    ABSCESS    OF   THE    UTERUS  253 

of  a  case,  probably  of  streptococcic  origin,  which  occurred  four  and 
one-half  weeks  after  the  delivery  of  the  patient.  Hysterectomy  was 
followed  by  recovery.  It  is  impossible  to  estimate  accurately,  from 
the  foregoing  reports,  the  proportion  of  these  cases  that  were  of 
gonorrheal   origin. 

Lea^  reports  a  case  occurring  in  a  multipara  following  labor. 
This  patient,  during  the  last  months  of  pregnancy,  had  a  profuse 
leukorrhea.  Labor  was  normal.  The  child  developed  ophthalmia. 
The  patient  convalesced  satisfactorily  until  the  twelfth  day,  when 
she  developed  hypogastric  pain.  This  continued,  although  not  of 
sufficient  severity  to  confine  the  patient  to  bed,  until  six  weeks  after 
delivery,  when  she  was  seized  with  intense  pain  in  the  lower  ab- 
domen, accompanied  by  rigor.  The  temperature  was  103.6°  F.,  and 
the  pulse  130.  The  abdomen  was  distended  and  tender.  Examina- 
tion revealed  an  enlarged  and  sensitive  uterus.  On  section,  the  con- 
dition was  seen  to  be  due  to  the  rupture  of  an  intramural  uterine 
abscess  that  was  situated  on  the  posterior  uterine  wall,  one  inch  below 
the  fundus.  The  appendages  were  normal.  The  patient  made  a  good 
recovery.  This  case  was  of  gonorrheal  origin.  In  1910  Sampson- 
reviewed  the  histories  of  4  cases  occurring  in  his  practice,  all  of  which 
followed  parturition.  None  of  these  was  due  to  gonorrhea.  Fer- 
guson' briefly  records  the  history  of  a  case  of  pelvic  inflammatory 
disease  occurring  in  the  puerperium,  in  which  numerous  small  intra- 
mural abscesses  were  present.  A  large  pyosalpinx  was  associated 
with  the  condition.  Recovery  followed  a  hysterectomy.  The  type 
of  infection  is  not  mentioned.  Barrows^  reports  7  cases,  only  1  of 
which  was  of  gonorrheal  origin.  The  reports  of  both  Sampson  and 
Barrows  are  most  \'aluabh>,  and  cover  the  etiology  and  other  important 
points  of  their  cases  thoroughly.  From  these  reports  it  will  be  seen 
that  of  11  carefully  studied  cases  of  intranuu'al  uterine  abscesses,  but 
1  was  of  gonococcal  origin.  If  we  add  to  this  series  the  case  reported 
by  Lea,  we  find  2,  or  16.G6  per  cent.,  of  all  cases  due  to  this  type  of 
infection.  Barrows  and  Sampson  are  of  the  opinion  that  intramural 
ab.scesses  of  the  uterus  are  more  frequent  than  is  generally  supposed, 
and  that  the  condition  is  seldom  diagnosed  before  operation.  The 
former  observer  believes  that  many  accumulations  of  pus  within  tlic 
uterine  wall  arc  discharged  into  the  uterine  cavity,  resulting  in  the 
recovery  of  the  patient,  without  definite  knowledge,  on  the  part  of  the 

'Lea:  .lour.  Ohstot.  and  ( lyn.,  liiil.  lOiiipiic,  I'.IOI,  vol.  v,  No.  2,  p.  l.'i!!. 
'Siiiiipson:   .Xiiicr.  Jour.  Olwlt't.,  .March,  li)l(l. 

"  KerRiL-ion,  J.  II.:  Tran.s.  Edin.  Olwt.  Sor.,  I'JO.'j-Oll,  vol.  xxxi,  p.  1;{1. 
'  Barrows:  Ainor.  Jour.  Obstct.,  .\pril,  1911,  p.  .57.5. 


254  GONORRHEA    IN    WOMEN 

medical  attendant,  of  the  presence  of  the  abscess.  Sudden  gushes 
of  pus  from  the  uterine  cavity,  followed  by  relief  of  symptoms,  have 
not  imcommonly  been  attributed  to  the  discharge  into  the  uterus  of 
the  contents  of  a  pyosalpinx.  Barrows  believes  that  many  of  these 
cases  are  in  reality  abscesses  of  the  uterus.  Again,  pus  inclosed  in  a 
shallow  pocket  beneath  the  mucosa  may  easily  be  evacuated  by  the 
curet,  which  has  been  brought  into  use  because  of  the  symptoms 
pointing  to  a  serious  inflammation  of  the  endometrium;  or  the  pus 
may  burrow  between  the  layers  of  the  broad  ligament,  and,  following 
the  round  ligament,  present  in  the  neighborhood  of  the  inguinal  ring, 
which,  being  opened  and  drained,  would  result  in  cure  of  the  patient 
under  a  mistaken  diagnosis.  Purulent  collections  in  the  posterior 
uterine  wall  and  low  down,  or  even  in  the  anterior  wall,  may  be  opened 
and  drained  imder  the  belief  that  they  are  ordinary  pelvic  abscesses. 

Sampson^  divides  intramural  uterine  abscesses  into  two  groups: 
The  first,  in  which  the  uterine  abscess  or  abscesses  are  the  chief  feature 
of  the  infection.  In  this  class  of  cases  the  condition  exists  as  a  dis- 
tinct clinical  entity.  The  second  group  consists  of  those  cases  in 
which  the  uterine  condition  is  secondary  in  pathologic  and  clinical 
importance  to  other  lesions  resulting  from  the  infection. 

Symptoms. — Intramural  uterine  abscesses  of  gonorrheal  origin 
may  be  either  single  or  multiple,  the  former  being  the  more  common. 
They  may  be  situated  either  in  the  cervix  or  in  the  body  of  the  uterus, 
but  are  apparently  more  frequent  in  the  latter  location  and  often 
single  or  few  in  number.  They  may  be  subperitoneal,  interstitial, 
or  submucous  in  type,  or,  as  previously  indicated,  may  extend  out- 
ward between  the  layers  of  the  broad  ligament  or  between  the  uterus 
and  bladder.  Mercade-  has  emphasized  their  frequency  near  the 
uterine  cornua.  The  abscesses  vary  in  size,  the  largest  one  of  which 
an  accurate  description  can  be  found  having  had  about  the  volume  of 
an  orange.  The  condition,  like  acute  metritis  without  abscess  forma- 
tion, is  frequently  preceded  by  labor,  miscarriage,  or  abortion.  In- 
([uiry  will  usually  elicit  the  presence  of  symptoms  of  gonorrhea  of  the 
endometrium  and  of  the  lower  genital  tract.  Pain  is  present  over 
the  lower  abdomen,  but  this  is  not  invariably  a  marked  feature.  The 
temperature  and  pulse  are  elevated,  and  the  blood  examiation  is 
indicative  of  suppuration.  The  other  symptoms  of  metritis  previously 
described  are  present.  Amenorrhea  or  irregular  and  profuse  men- 
struation may  be  observed.  All  the  symptoms  are  intensified  at  the 
menstrual  periods.     Examination  of  such  a  case  reveals  tendernesi 


'  Sampson,  C:  Amer.  Jour.  Obstct.,  March,  1910. 

■  Mercade;  Annal.  de  Gyn.  et  d'obstet.,  1907,  second  series,  vol.  iv,  p.  29. 


1 

I 


GONORRHEAL   INTRAMURAL    ABSCESS    OF    THE    L'TERfS  255 

over  the  lower  abdomen;  the  uterus  is  enlarged,  and,  if  the  case  is 
one  of  puerperal  origin,  involution  is  delayed.  On  palpation  the 
uterus  will  be  found  to  be  soft,  boggy,  and  sensitive  to  pressure.  It 
may  in  some  cases  be  possible  to  palpate  a  softened  swelling,  originat- 
ing in  the  uterus,  in  which  fluctuation  can  be  detected.  That  the 
appendages  -are  not  necessarily  involved  is  proved  by  the  cases  of 
Lea^  and  Barrows.-  The  cervix  and  lower  genital  tract  usually  exhibit 
evidences  of  gonorrhea. 

Diagnosis. — Intramural  uterine  abscesses  are  difficult  to  diagnose, 
and  may  be  mistaken  for  a  number  of  other  pathologic  conditions. 
Ordinary'  pelvic  inflammatory  disease  with  extensive  involvement 
of  the  appendages  may  produce  lesions  that  render  differentiation 
from  this  condition  impossible.  If  the  appendages  are  normal,  the 
diagnosis  is  facilitated,  as  in  this  case  the  normal  ovaries  may  be 
palpated.  Uterine  abscesses  must  also  be  distinguished  from  uterine 
myomata,  and  particularly  from  softened  and  degenerated  tumors. 
The  anamnesis  will  usually  be  of  great  aid  in  these  cases,  as  in  the 
case  of  mj'omata  uterine  hemorrhages,  often  extending  over  a  number 
of  years,  and  frequently  associated  with  a  thin,  leukorrheal  discharge, 
are  generally  present,  whereas  in  case  of  intramural  abscess  the  history 
frequently  shows  the  condition  to  have  had  its  origin  shortly  after 
childbirth  or  following  a  miscarriage.  Furthermore,  myomata  are 
usually  multiple,  and  evidences  of  infection  are  lacking;  in  the  case 
of  a  single,  softened  mj^oma,  however,  especially  if  it  is  associated 
with  a  gonorrhea  of  the  lower  uterine  tract,  the  differential  diagnosis 
might  easily  be  rendered  impossible.  Small  ovarian  tumors  in  which 
partial  torsion  has  occurred  and  adhesions  exist  often  simulate  ab- 
scesses of  the  uterus.  In  many  cases  the  probable  diagnosis  of  this 
condition  can  be  made  only  by  exclusion.  If,  however,  the  facts  are 
borne  in  mind  that  gonorrheal  uterine  abscesses  are  associated  with 
gonorrhea  of  the  lower  genital  tract ;  that  they  most  frequently  occur 
at  or  near  the  cornua  of  the  uterus;  that  they  often  have  their  origin 
in  the  puerperium;  that  the  infection  is  usually  of  a  low  grade,  com- 
pared with  that  produced  by  the  streptococcus,  and  that  the  abscesses 
are  accompanied  by  concomitant  symptoms  of  metritis  and  endome- 
tritis— a  tentative  diagnosis  should  be  possible  in  many  cases.  If 
untreated,  the  result  will  depend  largely  upon  the  number  and  loca- 
tion of  the  abscesses.  If  situated  in  the  cervix,  rupture  into  tlie  vagina 
may  occur  and  be  followed  by  sjjontaneous  cure.  Rupture  into  tlie 
peritoneal  cavity  may  take  place,  setting  up  a  pelvic  or  a  general  in- 

'  Lea:  Jour.  Obst.  and  Gyn.,  Brit.  Emp.,  1904,  vol.  v,  No.  2,  p.  1.59. 
'  Barrow.s:  Amer.  Jour.  Obst.,  April,  1911,  p.  .57.5. 


256  GONORRHEA    IN   WOMEN 

fection.  The  abscess  may  rupture  into  the  endometrial  cavity  or 
into  the  bladder  or  intestines,  especially  the  rectum  or  sigmoid  flexure, 
or  the  pus  may  burrow  between  the  layers  of  the  broad  ligament, 
finally  presenting  in  the  vagina  as  a  pelvic  abscess,  or  it  may  follow 
the  course  of  the  round  ligament  and  point  in  the  inguinal  region.  In 
rare  cases  the  pus  may  become  sterile  and  finally  be  absorbed.  Bar- 
rows^ reports  a  case  in  which  a  calcareous  deposit  was  formed  in  an 
old  uterine  abscess  and  simulated  a  calcareous  myoma. 

Treatment. — This  depends  largely  upon  the  location  of  the  abscess. 
If  it  is  so  situated  that  the  pus  may  be  evacuated  without  traversing 
the  peritoneal  cavity,  the  abscess  should  be  opened  and  drained  at 
once.  In  all  pelvic  infections,  and  especially  if  they  are  of  gonococcal 
origin,  the  general  tendency  at  present  is  very  properly  toward  delay- 
ing operation  until  the  acute  symptoms  have  passed.  This  is  par- 
ticularly true  if  the  infection  is  one  that  has  arisen  during  the  puer- 
perium.  For  this  reason,  if  a  uterine  abscess  is  diagnosed,  palliative 
treatment  should  be  instituted  provided  it  is  impossible  to  evacuate 
the  pus  extraperitoneally.  The  patient  should  be  confined  to  bed, 
the  bowels  regulated,  and  a  nutritious,  but  easily  assimilated,  diet 
prescribed.  If  the  case  is  a  non-puerperal  one,  or  if  the  os  is  firmly 
contracted,  frequent  hot  vaginal  irrigations,  together  with  the  applica- 
tion of  local  heat  by  means  of  turpentine  stupes  or  large  hot  poultices 
to  the  abdomen,  are  indicated.  Stimulation  may  in  some  cases  be 
required.  Ergot,  owing  to  the  fact  that  it  causes  uterine  contraction, 
should  not  be  administered.  (For  details  of  the  palliative  treatment 
of  pelvic  inflammatory  disease  see  the  chapter  dealing  with  this  con- 
dition.) The  patient  should  be  treated  in  a  hospital  and  watched 
carefully,  so  that  if  symptoms  of  rupture  of  the  abscess  occur,  an 
abdominal  section  can  at  once  be  performed.  If  the  palliative  treat- 
ment is  successful,  the  operation  should  be  delayed  as  long  as  the 
patient  continues  to  improve,  or  until  sufficient  time  has  been  allowed 
to  elapse  for  the  pus  to  become  sterile.  Under  such  circumstances 
the  abdominal  route  is  to  be  preferred  to  the  vaginal,  and  should 
always  be  employed. 

Two  forms  of  operative  procedure  are  open  to  choice — incision  and 
drainage  of  the  abscess  and  hysterectomy.  Noble-  reports  that 
hysterectomy  has  been  attended  with  a  mortahty  of  25  per  cent., 
whereas  in  11  reported  cases  of  incision  and  drainage  none  of  the 
patients  died.     Cragin^  mentions  5  cases  of  multiple  intramural  uterine 

'  Barrows:  Amer.  Jour.  Obst.,  April,  1911,  p.  575. 

2  Noble:  Trans.  Amer.  Gyn.  Soc.,  1906,  vol.  xx.xi,  p.  296. 

'  Cragin:  Amer.  Jour.  Obst.,  1900,  vol.  liii,  p.  779. 


I 


GONORRHEAL   INTRAMURAL   ABSCESS    OF    THE    UTERITS  257 

abscesses  occurring  at  the  Sloane  Maternity,  upon  whom  hysterectomy 
was  performed.  The  mortaUty  was  60  per  cent.  Harrow^  also  briefly 
reports  a  case  of  multiple  abscess  of  the  uterus  caused  by  the  strepto- 
coccus cured  by  hysterectomy.  Vineberg-  mentions  two  cases  during 
the  course  of  a  discussion  on  puerperal  thrombophlebitis  in  which  the 
uterus  was  studded  with  abscesses,  varying  in  size  from  a  pea  to  a 
walnut.  Davis^  records  the  history  of  a  case  in  which  an  intramural 
abscess  occurred  in  a  patient  on  whom  a  cesarean  section  had  been 
performed.  The  woman,  having  been  discharged  from  the  hospital 
on  the  fifteenth  day,  returned  on  the  twenty-ninth  day  and  died  ten 
days  later.  The  location,  size  of  the  abscess,  and  variety  of  infection 
are  not  mentioned.  Robins*  has  reported  a  case  that  occurred  in 
a  patient  twenty-seven  j^ears  of  age,  two  weeks  after  childbirth; 
until  this  time  the  puerperium  had  been  normal.  The  symptoms 
consisted  of  pain  in  the  lower  part  of  the  abdomen,  in  the  right  side, 
and  other  evidences  of  infection.  Supravaginal  hysterectomy  showed 
a  single  abscess  in  the-  posterior  uterine  wall  near  the  fundus,  which 
contained  about  2  ounces  of  thick,  creamy  pus.  The  etiology  of  the 
lesion  is  not  mentioned  in  the  report,  but  the  fact  that  the  tubes  were 
found  to  be  normal  and  the  ovaries  were  adherent  is  against  the  gono- 
coccal origin  of  the  condition.  Harrigan"  has  reported  the  history  of  a 
case  in  which  the  patient  had  given  birth  to  a  child  four  days  prior  to 
her  admission  to  the  hospital.  She  suffered  from  cough  and  the  usual 
symptoms  of  infection  of  the  lower  abdomen.  At  operation  a  large 
mass  was  found,  consisting  of  uterus  and  adherent  sigmoid.  A  large 
abscess  was  found  on  the  posterior  uterine  wall,  which  had  ruptured 
into  the  parametritic  tissues.  Hysterectomy  was  followed  l)y  recover}'. 
The  type  of  infection  is  not  stated. 

Barrows"  favors  drainage  of  these  cases,  and  is  particularly  care- 
ful not  to  break  up  adhesions  for  fear  of  opening  up  avenues  of  in- 
fection. To  effect  drainage,  he  employs  a  large  rubber  tube,  from  V2 
to  5^4  iiicli  ill  diameter.  This  tube  is  carried  well  into  the  abscess 
cavity,  and  held  in  position  by  an  ingenious  suture  that  passes  through 
the  abscess  wall  and  rubber  tube  and  is  tied  outside  the  wountl.  This 
suture  keeps  the  tube  in  place,  and  yet  may  be  loosened  at  any  time 
without  causing  pain  or  disconifort  to  the  patient. 

The  choice  of  the  operation  is  dependent  upon  a  number  of  factors, 

'  Harrow,  .J.  A.:   Bull.  Lying-in  Hosp.,  New  York,  March,  lUll,  p.  172. 
'  Vineberg,  H.  M.:  Jour.  Ainer.  Med.  .\ssoc.,  July  20,  1912,  p.  1G4. 

*  Davis,  A.  B.:  Amcr.  .lour.  Obst.,  December,  1912,  p.  940. 

*  Kobin.s,  C.  U.:  (Jltl  Dominion  Med.  and  Surg.  Jour.,  1911,  vol.  xiii,  p.  277. 
'  llarrigan,  \.  H,:   .Vnier.  Jour.  ObMleL,  September,  1912,  p.  46S. 

'  Barrows:   Luc.  cil. 
17 


258  GONORRHEA   IN   WOMEN 

which  are  generally  similar  to  those  that  govern  the  operator  in  making 
his  decision  in  cases  of  ordinary  pelvic  inflammatory  disease.  The 
type  of  infection  is  important  in  determining  this  point.  If  the  ab- 
scess is  single,  large,  walled  off,  and  is  so  situated  that  drainage  can  be 
satisfactorily  established,  this  operation  is  the  safer  one  to  perform. 
If,  however,  the  appendages  are  extensively  involved,  hysterectomy 
offers  the  best  hope  of  securing  an  entire  symptomatic  cure.  In 
operating  on  these  cases  special  care  should  be  taken  to  avoid  contam- 
ination of  the  peritoneal  cavity. 

The  following  is  the  history  of  a  case  that  was  operated  upon  in 
the  Gynecological  Department  of  the  University  of  Pennsylvania 
Hospital : 

Path.  No.  4i08. — Age,  twenty-five  years.  Shortly  after  marriage, 
four  years  ago,  a  profuse  purulent  leukorrhea  and  symptoms  of  ure- 
thritis appeared,  followed  later  by  a  labial  abscess.  One  child  three 
years  ago.  The  puerperium  was  complicated  by  pelvic  peritonitis. 
Since  then  sterility  and  occasional  attacks  of  pelvic  peritonitis.  For  the 
last  year  has  had  a  cough,  which  has  not  yielded  to  treatment,  and  a 
slight  loss  of  weight.  Examination  on  admittance  to  th^  hospital  showed 
a  small  tuberculous  lesion  in  the  left  apex  and  a  moderately  massive 
pelvic  inflammatory  disease.  It  was  the  latter  condition  that  brought 
the  patient  to  the  hospital.  Diplococci,  morphologically  and  tinctori- 
ally  similar  to  gonococci,  were  demonstrated  in  the  secretions  from 
the  cervix  and  from  one  of  Bartholin's  glands.  A  supravaginal  hys- 
terectomy and  a  bilateral  salpingo-oophorectomy  were  performed. 
Convalescence  was  somewhat  prolonged,  but  otherwise  normal.  The 
pathologic  examination  of  the  uterus  and  appendages  showed  thejn 
to  have  the  usual  appearance  of  pelvic  inflammatory  disease.  The 
tubes  were  converted  into  pyosalpinges.  The  abdominal  ostia  were 
closed,  and  no  fimbrite  could  be  distinguished,  nor  were  there  any  tu- 
bercles present  upon  the  peritoneal  surface.  One  ovary  was  the  seat 
of  a  small  abscess,  evidently  the  result  of  an  infection  of  a  corpus 
luteum;  the  other  was  enlarged,  covered  with  adhesions,  and  con- 
tained a  number  of  retention  cysts.  The  uterus  was  normal  in  size, 
and  in  the  left  cornua,  somewhat  anterior  to  the  median  line,  was  a 
semifluctuant  swelling,  2.5  by  2  by  1.5  cm.  Histologic  examination 
showed  this  to  be  an  intramural  abscess,  not  communicating  with 
the  tube.  No  gonococci  could  be  demonstrated  in  the  appendages 
or  in  the  intramural  abscess.  Numerous  tubercles,  many  of  which 
contained  typical  giant-cells,  were  present.  This  case  appears  to 
have  been  one  in  which  tuberculosis  was  implanted  upon  a  preexist- 
ing gonococcal  infection.  Whether  the  intramural  abscess  was  the 
result  of  tuberculosis  or  of  gonorrhea  it  is  impossible  positively  to  de- 
termine. 


CHAPTER  XII 

GONORRHEA  OF  THE  FALLOPIAN  TUBES  AND  OVARIES 

Gonorrhea  of  the  endometrium  may,  and  frequently  does,  extend 
to  the  tubes,  and  from  these  to  the  ovaries.  Gonorrheal  infection 
has  been  observed  to  reach  the  tubes  in  less  than  two  weeks  after  the 
initial  contamination  of  the  cervix.  This,  however,  is  unusual;  as 
a  rule,  a  much  longer  time  elapses  before  involvement  of  these  struc- 
tures takes  place.  The  relative  frequency  with  which  the  appendages 
are  invaded  in  comparison  with  gonorrhea  of  the  endometrium  is 
difficult  to  estimate  accurately,  but  it  seems  likely  that  if  the  mucosa 
of  the  body  of  the  uterus  becomes  infected,  in  the  majority  of  cases, 
at  least,  the  disease  extends  to  the  tubes,  and  from  the  latter  to 
the  ovaries.  ^lenge,^  in  combining  the  statistics  of  Bumm,  Stein- 
schneider,  Fabry,  Briinschke,  Brose,  and  Welander,  found  that  the 
tubes,  ovaries,  and  pehdc  peritoneum  were  involved  in  25  per  cent,  of 
the  acute  and  in  50  per  cent,  of  the  chronic  cases.  As  Bumm-  has 
amplj^  proved,  and  as  previously  stated  in  this  work,  the  gonococcus 
is  chiefly  a  surface  microorganism,  so  that  the  first  lesion  produced  in 
the  tube  by  this  type  of  infection  is  a  catarrhal  inflammation.  Tlie 
inflammation,  however,  quickly  spreads  from  the  superficial  portions 
to  the  deeper  layers  of  the  tube,  so  that  in  advanced  cases  the  muscu- 
laris  and  serosa  are  extensively  involved.  Wertheim^  and  others  have 
repeatedly  demonstrated  the  presence  of  gonococci  in  the  depths  of 
the  tubal  wall.  A  moderate  amount  of  cellulitis  is  usually  present 
as  an  accompaniment  of  advanced  tubal  disease.  Gonorrhea  travels 
by  continuity  along  the  mucous  membrane.  Rare  exceptions  to  this 
are  occasionallj'  noted,  as  sometimes  in  cases  of  extensive  cellulitis 
or  in  gonorrheal  endocarditis  and  other  metastatic  gonorrheas.  As  a 
result  of  the  salpingitis  an  inflammatory  exudate  forms,  which,  when 
it  e.scapes  from  the  abdominal  ostivun,  produces  at  first  a  peri-oophor- 
itis  and  localized  peritonitis.  This  may  increase  in  gravity  until  an 
oophoritis  or  even  an  ovarian  abscess  results.  The  same  cause  brings 
about  a  more  or  less  extensive  pelvic  jjeritonitis,  which  is  usually 
most  marked  in  tho.se  areas  innnediately  surrounding  the  tuljal  open- 

'  Menge,  V.:  Handb.  d.  Geschlechtskrankheitcn,  Vienna,  I'JIO. 
'  Bumm,  E.:  Tlierap.  d.  Gcgenwart,  190!),  No.  1,  p.  51. 
'  WerLhcim,  E.:  Ccnlrulbl.  f.  Gyn.,  189G,  No.  4)S,  p.  1-'0<J. 
259 


260  GONORRHEA    IN   WOMEN 

ings.  Adhesions  of  the  tubes,  ovaries,  uterus,  and  adjacent  structures 
are  thus  produced.  In  many  cases  the  abdominal  ostia  of  the  tubes 
become  closed,  and  the  tubal  contents  are  thus  walled  off  from  the 
peritoneal  cavity.  Nevertheless,  during  subsequent  exacerbations  of 
the  pehic  infiammatorj^  disease  more  pus  or  exudate  from  the  tubes 
frequently  leaks  out  through  the  tubal  openings,  and  toxins,  or  even 
gonococci,  escape  through  the  walls  of  the  oviducts,  so  that  in  ad- 
vanced cases  the  entire  contents  of  the  pelvis  may  be  found  matted 
together  in  a  mass  of  dense  adhesions.  Owing  to  the  increased  weight 
of  the  tubes  during  the  early  stages  of  the  inflammation,  these  organs 
sink  deeper  into  the  pelvis  and  are  not  infrequently  found  adherent 
to  the  posterior  surface  of  the  broad  ligament,  to  the  rectum,  or  in 
Douglas'  culdesac.  In  advanced  cases  of  pelvic  inflammatory  disease 
accumulations  of  pus  may  be  found  between  the  adnexa  and  the  ad- 
jacent structures,  and  walled  off  from  the  general  peritoneal  cavity 
by  adhesions.  Both  appendages  are  generally  involved,  although  not 
infrequently  infection  on  one  side  may  antedate  that  on  the  other. 
It  is  not  usual,  however,  to  find  a  large  inflammatory  mass  composed 
of  a  pyosalpinx  and  an  inflamed  ovary  on  one  side,  whereas  on  the 
other  little  more  than  a  perisalpingitis  will  be  found. 

The  number  of  previous  attacks  of  acute  pelvic  peritonitis  are  of 
importance  in  this  connection.  After  a  patient  has  had  a  number  of 
attacks  it  is  rare  to  find  a  normal  tube  on  either  side;  so,  also,  if  a 
pyosalpinx  has  been  present  on  one  side,  it  is  rather  unusual  for  the 
opposite  tube,  to  be  entirely  normal.  No  hard  and  fast  rule  can, 
however,  be  formulated  regarding  this  point. 

Pelvic  inflammatory  disease  may  be  produced  by  germs  other 
than  the  gonococcus,  although  this  organism  is  the  most  frequent 
causative  agent.  The  etiology  of  pelvic  inflammations  is  of  the  ut- 
most importance,  as  the  prognosis  varies  quite  widely  in  the  different 
types  of  infection.  If  it  were  possible  for  the  surgeon,  before  com- 
mencing his  operation,  to  know  positively  what  form  of  infection  he  was 
dealing  with,  a  great  advantage  would  be  gained.  Unfortunately, 
this  is  not  practicable  in  all  cases,  for  occasionally  rare  microorganisms, 
such  as  some  of  the  air  bacilli,  or  mixed  infections  will  defy  all  diag- 
nostic means  except  the  incubator,  and  this  is,  of  course,  not  available 
until  the  abdomen  has  been  opened  and  is,  therefore,  valueless  as  a 
surgical  guide.  Nevertheless,  the  great  majority  of  pelvic  infections 
may  be  classed  under  three  headings:  the  gonococcal,  the  pyogenic 
(streptococcus  or  staphylococcus),  and  the  tuberculous.  The  dif- 
ferentiation between  these  varieties  is  not  usually  difficult.  The 
relative  frequency  with  which  the  gonococcus  is  found  will  be  shown 


1 


GOXORRHEA   OF   THE   FALLOPIAN   TUBES   AND   OVARIES  261 

by  the  following  statistics:  Andrews^  reports,  in  the  order  of  their 
frequency,  the  following  microorganisms:  Gonococcus,  43  percent.; 
pyogenic  (streptococcus  and  staphylococcus),  24  per  cent.;  colon 
bacillus,  5  per  cent.;  pneumococcus,  4  per  cent.;  tubercle  bacillus, 
1  per  cent,  to  3  per  cent.  Menge-  records  the  results  obtained  from 
cultures  of  pus  from  106  cases  of  pyosalpinx:  Sterile,  68,  or  64  per 
cent.;  gonorrheal,  22,  or  21  per  cent.;  tuberculous,  9,  or  8  per  cent.; 
streptococcal,  4,  or  4  per  cent.;  staphylococcal,  1,  or  0.96  per  cent.; 
anaerobic  bacilli,  2,  or  3  per  cent.  Ki-6nig'  reports  the  bacteriologic 
examinations  of  122  cases  of  suppurating  tubes  as  follows:  Sterile, 
75,  or  61  per  cent.;  gonococcal,  28,  or  23  per  cent.;  tuberculous,  8,  or 
7  per  cent.;  pyogenic,  4,  or  3  per  cent.;  other  forms,  7,  or  6  per  cent. 
Miller^  examined  pus  from  43  cases  of  pyosalpinx,  ovarian  abscess,  and 
other  inflammatoiy  adnexal  lesions,  and  found  33  sterile,  7  gonococcal, 

I  pyogenic,  and  2  unidentified  forms  of  microorganisms.  Hyde,^ 
in  an  examination  of  2973  cases,  excluding  those  of  tuberculous  origin, 
reported  the  tubal  contents  sterile  in  1998  cases,  or  67  per  cent.  The 
gonococcus  was  recovered  in  579  cases,  or  19  per  cent.,  whereas  other 
or  mixed  infections  were  present  in  456  cases,  or  15  per  cent.  Xoeg- 
gerath  and  Wertheim*  examined  312  cases,  with  the  following  results, 
excluding  all  tubercular  specimens:  Sterile,  122,  or  39  per  cent,  of  cases; 
gonococci  were  found  in  56  cases,  or  18  per  cent.;    streptococci,  in 

II  cases,  or  4  per  cent.;    staphylococci,  in  6  cases,  or  2  per  cent. 
Pankow'  has  reported  that  statistics  computed  from  the  University 

Clinic  of  Freiberg,  these  show  43  per  cent,  of  suppurating  tubal  lesions 
due  to  gonorrhea,  22  per  cent,  to  tuberculosis,  and  22  per  cent,  to  secon- 
dary infection  from  the  appendix.  Schridde,**  however,  has  not  seen  a 
single  case  due  to  appendicitis  out  of  280  under  his  personal  observa- 
tion. Heyneman,^  from  an  analysis  of  47  cases,  showed  that  58.8  per 
cent,  were  due  to  the  gonococcus,  23.5  per  cent,  to  the  streptococcus, 
11.7  per  cent,  to  the  tubercle  bacillus,  and  5.8  per  cent,  to  the  staphj^- 
lococcus.     Lock,'"  in  22  cases,  found  gonococci  in  3;  10  were  sterile,  and 

'Andrews:  Quotcil  hy  (lihndrc.  ,1.  I{.:   Aincr.  .lour.  Ohsict.,  April,  KUD,  p.  VMi. 

■  McnRc:  Ccntnill)!.  f.  Gyn.,  ISi).'),  vol.  xix,  p.  7i)i). 

'  Kroniu,  Menge  and:  Bact.  d.  weibl.  GenitalkanaLs,  Leipzig,  1S97,  pt.  1,  p.  204. 

'  .Miller:  Quoted  hy  Cro.sscn:  Trans.  .\mor.  Gyn.  .Soe.,  I'hiladelpliia,  190i),  vol.  xxxiv, 
p.  tiOJ. 

>  Hyde,  C.  R.:   Ainer.  .Jour.  Obstct.,  1908,  vol.  Ivii,  p.  49(i. 

'  Noegnerath  and  Wertheim:  Quotctl  by  Crossen:  Trans.  Anier.  Gyn.  Soe.,  1909, 
vol.  xxxiv,  p.  ()()'J. 

'  I'ankow:  (^uolecl  by  de  Bovis:  La  Scmainc  MMieale,  September  4,  1912. 

'Scliridde:   (Quoted  by  de  Bovis:   Loc.  cit. 

■  Ileynenian:  Zeit.  f.  Gel.,  u.  Gyn.,  1912. 

"  Lock,  N.  I''.:  .Jour.  Obst.  and  Gyn.,  Brit.  lOup.,  .July,  1912,  [).  1. 


262  GONORRHEA    IN    WOMEN 

in  the  remainder  10  different  organisms  were  demonstrated.  An  analy- 
sis of  the  foregoing  statistics  shows  tliat  of  3501  cases,  the  gonococcus 
was  demonstrated  in  the  lesions  718  times,  or  17.4  per  cent.  A  per- 
centage of  17.4  does  not,  however,  by  any  means  represent  the  actual 
proportion  of  those  cases  which  were  of  gonorrheal  origin;  for,  apart 
from  the  well-known  difficulty  of  demonstrating  the  gonococcus  by 
either  culture  or  staining  methods  in  chronic  cases,  it  is  a  well- 
established  fact,  and  one  of  great  clinical  importance,  that  long  en- 
capsulation tends  to  destroy  the  gonococcus,  perhaps  by  its  own  toxins. 

Gurd,'  after  a  careful  study  of  20  cases  of  salpingitis,  states  that  he 
believes  the  gonococcus  to  be  the  exciting  factor  in  the  production 
of  the  affection  in  at  least  80  per  cent,  of  his  series.  He  further  adds 
that  the  reason  many  bacteriologic  tests  for  this  organism  are  negative 
is  that  the  material  for  examination  is  obtained  from  the  free  pus 
in  the  abscess  cavity.  If  the  material  is  removed  by  curetage  from 
the  wall  of  the  abscess,  there  is  a  much  greater  likelihood  of  obtaining 
positive  results,  as  the  gonococci  persist  in  a  virulent  state  in  such 
areas  long  after  those  in  the  free  fluid  become  attenuated  or  are 
totally  destroyed.  It  is  well  recognized  that  gonococci  can  be  demon- 
strated in  the  tubes  in  only  a  small  proportion  of  chronic  cases  of 
salpingitis,  even  by  the  most  painstaking  and  thorough  bacteriologic 
examination.  This  must  be  considered  in  analyzing  the  foregoing 
figures.  Furthermore,  in  many  cases  the  gonococcus  appears  to 
prepare  the  soil  for  subsequent  infection  by  other  microorganisms,  so 
that  even  in  c^ses  in  which  other  organisms  are  demonstrated,  gono- 
cocci may  have  caused  the  primary  lesions.  A  careful  study  of  the 
history  of  each  case,  together  with  a  thorough  examination  of  the 
cervix,  urethra,  and  vulvovaginal  glands,  would  throw  light  upon 
this  point. 

Guthrie  collected  statistics  from  15  surgeons  in  Iowa,  and  found 
that  70  per  cent,  of  all  cases  of  pelvic  inflammatory  disease  were  of 
gonococcal  origin.  Price  claims  that  90  per  cent,  of  all  pelvic  in- 
fections are  of  gonococcal  origin.  Norris  places  the  proportion  at 
80  per  cent. ;  Pozzi  and  Frederic,  at  75  per  cent. ;  Clark,  at  50  per 
cent.;  Heynemann,^  at  66  per  cent.;  Robb,  at  25  per  cent.;  Davis 
and  Noble,  at  5  to  10  per  cent.  The  diversity  of  results  obtained  can 
doubtless  be  largely  accounted  for  by  considering  the  material  from 
which  the  statistics  were  compiled,  for,  as  is  well  known,  some  clinics 
operate  on  large  numbers  of  pelvic  inflammatory  cases,  whereas  in 
others  they  will  but  comparatively  rarely  be  observed. 

'  Gurd,  F.  B.:  Jour.  Med.  Research,  1910,  vol.  xxiii;  new  series,  vol.  xviii,  pp.  151-175. 
2  Heynemann:  Zeit.  f.  Geb.  u.  Gyn.,  1912,  vol.  Ixx,  No.  3. 


GONORRHEA   OF   THE   FALLOPIAX  TfBES   AND   OVARIES  263 

The  great  importance  of  accurate  diagnosis  in  respect  to  the 
microorganism  producing  the  lesion  is  shown  by  a  study  of  the  beha- 
vior of  the  various  organisms  within  the  Fallopian  tubes.  A  large  pro- 
portion of  gonorrheal  adnexal  lesions  ultimately  become  sterile.  The 
gonococcus  doubtless  constitutes  primarily  the  infective  type  of  micro- 
organism in  many  of  those  cases  in  which  no  growth  upon  culture- 
media  can  be  obtained.  The  time  required  to  effect  death  or 
successful  attenuation  of  the  gonococcus  within  the  Fallopian  tube 
is  from  one  and  one-half  to  three  months,  although  in  exceptional 
cases  the  microorganisms  may  survive  a  longer  period,  as  shown  by 
Neisser,^  who  examined  143  cases  of  gonorrheal  pelvic  inflammatory 
disease,  all  of  which  had  remained  latent  for  a  period  of  at  least  two 
months  and  some  for  as  long  as  eight  years.  In  8  cases  of  this  series 
gonococci  were  found.  It  is  probable  that  in  most  of  these  8  cases 
the  virulence  was  greatly  attenuated.  If  both  ends  of  the  tube  are 
entireh'  occluded  and  the  tubal  walls  are  thick,  the  death  of  the  in- 
fecting microorganism  occurs  more  rapidlj'  than  if  a  more  or  less  con- 
stant leakage  of  the  tubal  contents  is  taking  place.  The  pyogenic 
microorganisms  are  much  more  erratic  than  the  gonococci,  and  fre- 
quently become  encapsulated,  not  losing  their  virulence  for  prolonged 
periods.  Thus  IVIiller-  reports  two  cases,  in  one  of  which  streptococci 
existed  for  six  years,  and  in  another,  for  twelve  years;  Martin'  men- 
tions a  case  of  nineteen  years'  duration.  In  not  a  few  cases  of  pel- 
vic inflammatory  disease  mixed  infections  are  present,  as  was  proved 
by  Hyde's'  statistics.  Aside  from  the  direct  influence  of  the  specific 
microorganism,  inflammation  of  the  uterine  adnexa  may  result  from 
the  action  of  toxins,  although  exactly  to  what  extent  this  occurs  has 
not  yet  been  definitely  determined.  Wertheim*  was  the  first  to  dem- 
onstrate the  presence  of  gonococci  in  pure  culture  in  salpingitis  and 
also  in  circumscribed  pelvic  peritonitis. 


ACUTE  PELVIC  INFLAMMATORY  DISEASE 
Symptoms. — These  vary  according  to  the  extent  of  the  lesion 
and  the  stage  of  the  disease.  Thus,  when  a  pyosalpinx  is  walled  off 
by  adhesions  it  prol)ably  will  not  cause  so  much  disturbance  as  a 
much  milder  inflammatory  process  of  a  tube  the  abdominal  ostium  of 
which  is  patulous  and  leaking. 

'  .N'oisser:   (Quoted  by  Crossen:   Trans.  Aiiicr.  (lyii.  Soc,  I'.H)'.),  vol.  xxxiv,  p.  M2. 
'  .Miller:  (iuoled  by  Kelly:  Oporativt-  Gynecology,  IS'J'J,  vol.  ii,  p.  211. 
'  Miirtin,  F.  H.:  Surg.,  Gyn.,  and  Obstet.,  April,  1907,  p.  501. 
*  Hyde:  Amer.  .Jour.  Ob.sl.,  1908,  vol.  Ivii,  p.  490. 
'  Wertheini:   .Arch.  f.  Gyn.,  Berlin,  vol.  xlii,  p.  1. 


264  GONORRHEA    IN    WOMEN 

The  extension  of  the  infection  from  the  uterus  to  the  Fallopian 
tube  usually  follows  a  menstrual  period,  or  the  emptying  of  a 
gravid  uterus.  When  there  is  a  latent  gonorrheal  infection  of  the 
endometrium,  the  disease  is  often  spread  to  the  tubes  by  some  intra- 
uterine manipulation,  performed  for  the  relief  of  dysmenorrhea  or 
sterility.  The  subjective  symptoms  are  similar  to  those  of  metritis, 
except  that  when  the  tubes  are  involved  the  pain  and  tenderness  are 
more  diffuse  and  are  not,  as  in  the  former,  confined  to  the  region  of  the 
uterus,  but  extend  over  the  affected  area.  Furthermore,  owing  to 
the  more  extensive  involvement  of  various  organs,  the  symptoms  are 
likely  to  be  more  severe.  Bumm'  and  Menge-  rightly  lay  especial  stress 
on  the  question  of  pain  as  a  diagnostic  feature,  and  believe  that  this 
is  always  much  more  severe  when  the  disease  extends  to  the  tubes 
than  when  it  is  confined  to  the  uterus.  In  the  latter  case  pain  is 
often  a  marked  symptom  only  at  the  menstrual  periods. 

The  symptomatology  of  salpingitis  and  its  accompanying  inflam- 
mation is  defined  only  with  extreme  difficulty,  owing  to  the  numerous 
structures  that  may  be  involved.  The  initial  symptom  indicative 
of  an  involvement  of  the  Fallopian  tubes  is  frequently  a  chill,  followed 
by  nausea,  vomiting,  malaise,  headache,  elevation  of  the  temperature, 
and  increased  pulse.  In  gonococcal  cases  the  temperature  rarely 
rises  above  103.5°  F.  or  the  pulse-rate  above  130,  and  more  frequently 
both  fall  below  these  figures.  A  blood-count  shows  an  increase  in 
the  number  of  leukocytes.  The  appetite  is  lost,  and  the  usual  symp- 
toms of  fever,  are  present.  Rectal  or  vesical  tenesmus  may  be 
marked  if  the  inflamed  appendages  are  adherent  to  or  press  against 
either  the  rectum  or  the  bladder.  Rectal  tenesmus  is  a  frequent  con- 
dition. The  disease  may  be  unilateral  or  bilateral;  in  some  cases 
both  tubes  are  infected  simultaneously,  whereas  in  others  only  one 
side  is  attacked.  As  the  inflammation  spreads  by  direct  extension 
from  the  endometrium,  infection  may  occur  at  any  time  while  the 
endometritis  persists.  The  severity  and  duration  of  the  attacks  vary 
quite  widely  in  different  cases.  The  local  symptoms  are  only  a 
moderately  reliable  indicator  as  to  the  extent  of  the  disease.  Not 
infrequently,  in  severe  cases,  owing  to  the  wide-spread  abdominal 
tenderness,  pain,  and  tympanites,  a  clinical  picture  suggestive  of 
general,  rather  than  pelvic,  peritonitis  will  be  presented.  Vaginal 
examination  at  this  time  will  reveal  evidences  of  gonorrhea  in  the 
lower  genital  tract.  The  uterus  will  be  found  enlarged,  softened,  and 
tender.     Induration  will  usually  be  present  in  one  or  both  vaginal 

'  Bumm:   Therap.  d.  Gegenwart,  1909,  No.  1,  p.  51. 

2  Menge,  K.:   Handbuch  d.  Gesehlec-htskrankheiten,  Vienna,  1910. 


GONORRHEA   OF  THE   FALLOPIAN   TUBES  AND   OVARIES  265 

fornices.  The  cervix  will  be  more  or  less  fixed,  and  attempts  to  move 
it  will  cause  pain,  not  only  in  the  uterus,  but  in  the  ovarian  regions 
as  well.  An  inflammatorj^  mass,  varying,  according  to  the  extent 
and  character  of  the  lesion,  from  a  slight  thickening,  induration,  or 
indistinct  sense  of  resistance  to  a  tumor  the  size  of  a  grape-fruit  or 
larger,  will  be  found  occupj'ing  the  region  of  the  appendages. 

During  the  acute  stage,  owing  to  tenderness  and  tympanites,  it  is 
often  impossible  accurately  to  outline  the  adnexal  lesions.  ^lenstrual 
disturbances  are  often  present,  but  these  are  probablj'  due  largely  to  the 
accompanj^ing  endometritis  and  metritis.  Ovarian  involvement  also 
influences  the  bleeding.  The  tubal  contents  at  this  stage  contain 
numerous  typical  gonococci.  The  duration  of  the  acute  attack  varies 
from  a  few  days  to  two  or  three  weeks.  Unless  complications  arise, 
the  disease  rarel}-,  if  ever,  ends  fatally,  but  usually  gradually  subsides 
and  merges  into  the  chronic  state. 

CHRONIC  PELVIC  INFLAMMATORY  DISEASE 
The  chronic  stage  of  pelvic  inflammatory  disease  can  almost  invari- 
ably be  traced  to  an  acute  attack,  but  occasionally,  in  mild  cases,  the 
disease  is  subacute  and  follows  an  almost  chronic  course  from  the  be- 
ginning. The  symptoms  varj^  according  to  the  extent  and  character  of 
involvement  of  the  pelvic  structures.  In  mild  cases,  during  this  stage, 
the  subjective  symptoms  may  be  almost  entirely  absent,  or  consist 
at  most  only  of  discomfort  at  the  menstrual  periods.  More  commonly, 
however,  the  disease,  for  the  first  year  or  two,  is  progressive.  Exacer- 
bations from  the  chronic  stage,  occurring  at  irregular  intervals,  caused 
by  leakage  of  the  tubal  contents,  may  occur  at  any  time,  but  are  more 
prone  to  occur  at  a  menstrual  period,  after  emptj'ing  of  a  pregnant 
uterus,  during  the  puerperium,  following  trauma,  such  as  intra-uterine 
manipulations  or  treatment,  or  even  after  excessive  or  violent  sexual 
intercourse.  In  this  way  extensive  pelvic  pathologic  changes  may  be 
produced  that  practically  render  the  patient  an  invalid. 

Menorrhagia  and  metrorrhagia  are  often  present,  together  with  the 
symptoms  of  cervical  gonorrhea.  In  exceptional  cases  amenf)rrhea  or 
scanty  menstruation  may  be  observed.  Although  no  definite  rule  can  be 
formulated  regarding  this  point,  it  is  probable  that  changes  in  men- 
struation bear  a  more  or  less  direct  relation  to  the  amount  of  ovarian 
involvement.  Boldt'  states  that  if  the  tubal  disease  does  not  cause 
pathologic  changes  in  the  ovaries,  the  menstrual  type  is  not  likely 
to  be  changed.  In  those  cases  of  hydrojis  tuba-  profluens  there  may 
be  an  occasional  noticeable  discharge  of  the  tubal  contents  through  the 

'  Boldl.  II.  .1.:   .Jour.  Aiii.T.  Med.  Assoc,  .Inly  i:i,  IIU.'.  p.  Kll. 


266  GONORRHEA    IN    WOMEN 

vagina,  followed  by  temporary  relief  of  symptoms  and  a  subsidence  of 
the  tul^al  enlargement.  Pain  in  the  lower  abdomen  is  generally  present, 
and  is  usually  most  marked  on  that  side  in  which  the  lesions  are  most 
severe.  In  some  cases,  owing  to  the  involvement  of  adjacent  sensory 
nerves,  pain  is  referred  to  the  thighs  or  external  genitalia.  Owing  to 
the  presence  of  numerous  adhesions,  distress  is  often  caused  by  the  peri- 
staltic movements  of  the  intestines — the  so-called  "gas  pains,"  the 
pain  being  colicky  in  character.  It  is  possible  that  in  some  instances 
colicky  pain  may  be  caused  by  contractions  of  the  tubal  walls.  The 
amount  of  pain  present  is  not  always  an  indication  of  the  extent  of 
the  inflammation,  as  in  some  very  serious  cases  the  patients  suffer 
only  a  slight  discomfort,  whereas  in  others  exhibiting  but  a  compara- 
tively mild  lesion  marked  subjective  symptoms  occur.  Indeed,  the 
general  excellent  physical  condition  and  small  amount  of  disability  are 
most  remarkable  in  some  cases.  They  are,  however,  the  exceptions. 
The  character  of  the  pain  may  also  vary  widely  in  different  cases. 
In  some  it  may  be  acute  and  agonizing,  whereas  in  other  patients  there 
may  be  merely  a  sensation  of  weight  and  dragging  in  the  pelvis.  As 
a  rule,  rest  in  bed  or  the  application  of  heat  to  the  lower  abdomen 
alleviates  the  pain.  Defecation  is  often  painful,  especially  in  those  cases 
in  which  the  appendages  are  adherent  to  the  rectum.  As  a  result, 
constipation  is  often  a  marked  feature.  It  is  caused  not  only  by 
actual  pressure  on  the  rectum,  but  is  often  due  to  the  fact  that,  be- 
cause of  pain,  the  act  is  delayed  as  long  as  possible,  and  a  costive 
habit  results.  .This  accumulation  of  hard  feces  within  the  pelvis 
tends  in  time  to  augment  the  pelvic  inflammation,  and  in  this  manner 
a  vicious  circle  is  established.  In  some  patients  the  symptoms  re- 
sulting from  the  sluggish  action  of  the  bowels  constitute  in  themselves 
a  marked  feature  of  the  case.  If  the  tube  and  ovary  lie  anterior 
and  are  adherent  to  the  bladder,  vesical  symptoms,  such  as  frequent 
and  painful  micturition,  are  more  or  less  pronounced.  Unless  a  pelvic 
examination  is  made,  the  condition  may  be  mistaken  for  cystitis,  while 
distention  of  the  bladder  or  the  emptying  of  a  distended  bladder  may 
cause  pain.  Pain  in  the  lower  lumbar  and  sacral  region  is  often  present, 
and  in  some  cases  is  most  severe.  Frontal  or  occipital  headache  may 
be  a  more  or  less  marked  symptom.  Dming  the  chronic  stage  the 
pulse  and  temperature  are  usually  normal,  for  during  this  period  the 
exudates  are  confined  by  adhesions.  For  the  same  reason  the  blood 
examination  is,  as  a  rule,  negative,  or  shows  only  a  slight  leukocytosis. 
All  the  symptoms  are  usually  ameliorated,  and  the  patient  generally 
feels  more  comfortable  early  in  the  morning  than  after  she  has  been 
about  for  some  time.     The  discomfort  is  increased  by  exercise  or  by 


GONORRHEA   OF  THE   FALLOPIAN  TUBES  AND   OVARIES  267 

the  pressure  of  tight  clothing  about  the  waist  or  lower  abdomen.  As 
a  rule,  the  more  chronic  in  nature  the  disease  is,  the  more  rarely  is 
pain  a  prominent  symptom.  The  symptoms  are  usually  more  pro- 
nounced for  a  few  daj's  prior  to  and  during  the  menstrual  periods. 
AVhen  the  menopause  has  become  established,  the  suffering  is  fre- 
quently alleviated  or  disappears  entirelj\  Dj-smenorrhea  is  almost 
always  present,  and  may  in  some  cases  be  the  chief  subjective  symptom. 

Although  the  character  of  the  dysmenorrhea  may  vary,  it  is  usually 
of  the  congestive  type.  It  generallj'  begins  from  twelve  to  forty-eight 
hours  before  the  appearance  of  the  menstrual  flow,  and  becomes  le.ss 
severe  after  the  second  or  third  day.  The  pain  is  of  a  dull,  heavy, 
aching  character,  and  occurs  in  the  lower  part  of  the  abdomen,  and 
is  frequently  worse  on  that  side  upon  which  the  lesions  are  most 
severe.  Backache  in  the  sacral  and  lower  lumbar  regions  is  often 
present.  During  the  dysmenorrhea  tenderness  is  increased  over  the 
diseased  areas.  At  the  menstrual  periods  pain  and  tenderness  in  the 
inguinal  regions  are  frequently  complained  of.  Dyspareunia  of  varying 
severity  usually  exists,  and  if  the  tubes  are  not  patulous,  absolute 
sterility  is  the  result.  As  a  rule,  the  fimbriated  extremitj'  of  the  tube 
becomes  occluded  early  during  the  course  of  the  inflammatory  process. 
So  long  as  the  uterine  end  of  the  oviduct  remains  patulous  and  in- 
fective material  escapes  through  the  uterine  cavit)-,  the  symptoms  of 
an  endometritis  will  persist. 

The  vermiform  appendix  is  involved  secondarily  in  a  large  proi)or- 
tion  of  cases  of  pelvic  inflanunatory  disease,  especially  when  the  right 
adnexus  is  affected,  the  condition  usually  taking  the  form  of  a  peri- 
appendicitis. As  a  result,  tenderness  over  McBurney's  point  is  often 
observed.  Exacerbations  from  the  chronic  stage  are  frequent,  es- 
pecially during  the  first  year  or  two  of  the  disease.  These  often  follow 
trauma,  or  may  result  from  no  assignable  cause.  The  recurrent 
attacks  of  jielvic  peritonitis  are  cau.sed  by  a  leakage  from  the  tube  of 
infective  material,  which  sets  up  local  peritonitis.  The  leakage  may 
occur  from  the  abdominal  ends  of  the  tube,  or  irritation  of  the  adjacent 
peritoneum  may  result  from  toxins  or  even  actual  gonococci  passing 
through  the  tubal  wall. 

Constitutional  .sj^mptoms  vary  widely,  according  to  the  individual 
case.  The  patient  is  usually  more  or  less  incapacitated  and  tires 
easily.  At  times  loss  of  weight,  anemia,  and  general  ill  health  are 
present,  although  in  other  ca.ses,  apart  from  the  pelvic  symptoms, 
the  patient  may  appear  to  be  robust  and  well.  Tenderness  over  the 
lower  abdomen  is  often  marked,  and  in  severe  cases  the  gait  may  \)o 
almost  characteristic,   the  patient   walking  slowly,  stoDjjiiig  forward, 


268  GONORRHEA    IN    WOMEN 

often  inclining  slightly  to  one  side  or  the  other,  a  hand  being  placed 
over  the  site  of  the  pain.  As  a  result  of  prolonged  suffering,  impaired 
general  health  and  neurasthenia  not  infrequently  result. 

Abdominal  palpation  reveals  the  presence  of  resistance  and  tender- 
ness over  the  affected  areas,  and  in  thin  subjects,  or  when  the  lesion  is 
massive,  a  tumor  may  at  times  be  felt  in  one  or  both  ovarian  regions. 

Vaginal  examination  reveals  the  evidence  of  gonorrhea  in  the  lower 
genital  tract.  Induration  and  tenderness  are  often  present  in  one  or 
both  vaginal  fornices.  The  cervix  is  somewhat  fixed,  and  attempts 
to  draw  it  down  or  move  it  in  any  direction  cause  pain  in  the  ovarian 
regions  and  the  broad  ligaments.  The  uterus  is  frequently  in  retro- 
position  and  adherent,  and  may  be  somewhat  enlarged.  The  tube 
and  ovary  are  often  bound  together  in  an  indistinguishable,  adherent, 
tender,  inflammatory  mass,  over  which,  in  cases  of  large  accumula- 
tions of  fluid,  fluctuation  may  be  elicited.  This  is  more  likely  to  be 
noticeable  in  thin  patients  and  in  those  in  whom  the  tubal  walls  are 
attenuated.  More  often  fluctuation  is  absent,  and  the  tumor  has  a 
hard,  elastic  feel.  Occasionally  the  ovary  can  be  palpated  as  a  sepa- 
rate structure,  but  frequently  this  is  not  practicable,  and  in  some  cases 
the  appendages  of  the  two  sides  cannot  be  differentiated.  The  in- 
flamed masses  may  be  bilateral  or  unilateral,  one  side  usually  being 
more  extensively  involved  than  the  other.  The  longer  the  disease 
has  persisted,  and  the  more  numerous  the  acute  exacerbations  have 
been,  the  more  likely  is  the  condition  to  be  bilateral.  In  long-standing 
chronic  cases,  .therefore,  bilateral  salpingitis  is  usually  present.  The 
differentiation  between  a  pyosalpinx,  a  hydrosalpinx,  and  a  hema- 
tosalpinx is  in  many  cases  impossible.  In  purulent  cases  a  slight 
elevation  of  temperature,  perhaps  of  a  half  or  one  degree,  is  significant. 
On  palpation  a  pyosalpinx  frequently  imparts  a  hard  or  doughy  sensa- 
tion to  the  examining  finger,  whereas  serous  tubal  accumulations  are 
more  elastic  and  often  less  adherent.  Inflammatory  hydrohemato- 
salpinges  give  the  same  general  sensation  on  palpation  as  do  simple 
serous  accumulations.  The  rare  cases  of  hematosalpinx  not  due  to 
tubal  pregnancy  impart  a  soft,  doughy  feel  to  the  examining  finger. 
The  typical  retort  shape  often  assumed  by  non-purulent  tubal  ac- 
cumulations sometimes  acts  as  a  guide  in  ascertaining  the  variety  of 
lesion  present. 

Occasionally  the  tubes  are  small  and  soft,  and  in  these  cases  the 
demonstration  of  salpingitis  by  means  of  palpation  is  extremely  dif- 
ficult and  may  be  impossible  without  the  administration  of  an  anes- 
thetic. Fixation  of  the  ovary  is  always  significant.  It  is  in  these 
cases  especially  that  the  history  will  be  of  great  assistance  in  formulat- 


GONORRHEA   OF  THE   FALLOPIAX  TUBES   AND   OVARIES  269 

ing  a  correct  diagnosis.  The  age  and  social  position  of  the  patient 
are  of  importance,  for  although  pelvic  inflammation  may  be  present 
in  virgins,  its  pathogenesis  in  these  cases  can  rarely  be  traced  to  gon- 
orrhea; on  the  other  hand,  this  type  of  infection  is  the  most  frequent 
in  the  married  and  among  women  of  loose  morals.  The  previous 
history  of  the  case  often  discloses  the  fact  that  the  symptoms  ap- 
peared after  a  labor  or  a  miscarriage  that  was  followed  bj'  "chills  and 
fever,"  or  the  patient  may  state  that  her  ti'ouble  originated  in  an 
attack  of  "inflammation  of  the  bowels."  Gonorrheal  salpingitis  is 
always  preceded  by  gonorrhea  of  the  lower  genital  tract,  so  that  a 
history  of  a  purulent  leukorrhea  or  other  evidence  of  infection  occur- 
ring shortly  after  marriage  or  after  a  suspicious  intercourse  is  of  especial 
significance.  In  these  cases  a  historj^  of  good  health  and  of  an  entire 
absence  of  pelvic  symptoms  prior  to  marriage  is  very  suggestive. 
Sterility,  either  absolute  or  of  the  "one-child"  variety,  provided  that 
no  means  to  prevent  conception  ha^•e  been  emploj'ed,  is  a  very  common 
feature  in  cases  of  pelvic  inflammation  of  gonorrheal  origin. 

A  remarkable  case  of  fecundation  after  bilateral  pyosali)ingitis 
has  been  reported  by  Gradl,'  in  which,  within  four  months  after 
bilateral  pus-tubes  had  been  diagnosed  during  a  laparotomy,  the 
patient  became  pregnant  and  subsequently  went  thi'ough  a  fairly 
normal  labor  and  puerperium.  Rupture  of  a  pus-sac  into  the  rectum 
had  taken  place  during  the  acute  stage  of  the  salpingitis,  and  discharge 
of  pus  through  the  anus  continued  until  the  middle  of  pregnancy. 
Gradl  believes  that  the  ovum  must  have  found  its  way  either  through 
one  of  the  tubes,  which  healed  spontaneously,  or  that  a  sinus  per- 
mitted a  comnmnication  between  the  ovary  and  the  closely  adherent 
tube,  so  that  the  Graafian  follicle  projected  into  the  lumen  of  the 
latter. 

Recurrent  attacks,  at  irregular  intervals,  of  pelvic  peritonitis, 
lasting  for  a  few  days  or  more,  the  interim  being  characterized  bj' 
comparative  health,  are  typical  of  this  type  of  infection.  In  many 
instances  chronic  invalidism  and  neurasthenic  symptoms  result. 

Diagnosis. — This  is  usually  readily  made  if  the  anamnesis  of  the 
case  is  considered  and  a  careful  examination  is  performed.  Excep- 
tional cases  may,  however,  be  encountered  in  which  it  is  difficult  to 
arrive  at  a  positive  diagnosis.  The  most  frcciuent  conditions  with 
which  pelvic  inflammatory  disease  of  gonorrheal  origin  is  likely  to  be 
confouniled  are:  Tuberculo.sis  of  the  tubes  and  ovaries;  small  ad- 
herent neoi)lasms,  especially  dermoid  cysts;  small  adherent  uterine 
tumors,  such  as  niyomata;    ectopic  pregnancy,  ]iarticularly  in  cases 

■  Cn.dl,  II.:   Zcnt.  f.  Cyn.,  April  27,  I'.UJ. 


270  GONORRHEA    IN   WOMEN 

of  tubal  rupture  and  suppuration;  cellulitis  of  the  broad  ligament, 
and  oophoritis  of  pyogenic  origin.  A  right-sided  gonorrheal  sal- 
pingitis may  be  mistaken  for  appendicitis.  The  differential  diagnosis 
between  gonorrheal  pelvic  inflammatory  disease  and  appendicitis 
is  not  usually  difficult.  Tuberculosis  often  occurs  in  virgins,  and 
is  not  infrequently  associated  with  tuberculous  lesions  in  other  parts 
of  the  body.  Dermoid  cysts  are  generally  unilateral,  and  a  normal 
ovary  may  often  be  felt  on  the  opposite  side.  These  tumors  are 
likely  to  occur  in  unmarried  young  women,  and  are  especially  prone 
to  be  found  lying  anterior  to  the  uterus  (Olshausen's  sign).  The 
history  is  often  of  great  aid  in  excluding  uterine  myomata.  Pehdc 
examination  usually  reveals  the  enlarged,  nodular  character  of  the 
uterus.  When,  however,  the  tumors  are  very  small  and  intramural 
in  type,  and  are  associated,  as  they  frequently  are,  with  adnexal 
inflammatory  lesions,  the  differential  diagnosis  is  particularly  difficult, 
and,  unless  the  asymmetry  of  the  uterus  can  be  distinguished,  mistakes 
may  easily  be  made.  Snegireff'  states  that  when  pain  is  due  to  an 
inflammatory  process,  it  is  generally  of  acute  onset,  and  then  gradually 
subsides.  Inflammatory  pains  are  accompanied  by  fever  and  other 
symptoms  of  infection,  and  the  application  of  cold  tends  to  relieve 
them,  whereas  in  pain  resulting  from  neoplasms,  the  converse  is  likely 
to  be  the  case.  The  history  in  cases  of  ectopic  pregnancy  and  the 
finding,  in  Douglas'  pouch,  of  a  doughy  mass,  having  the  peculiar, 
almost  characteristic,  crepitant  feel  produced  by  clotted  blood,  will 
usually  be  sufficient  to  establish  the  diagnosis. 

The  differential  diagnosis  before  rupture  is  usually  comparatively 
easy;  the  amenorrhea,  followed  by  irregular  bleeding,  the  concomi- 
tant symptoms  of  pregnancy,  the  absence  of  previous  attacks  of  pelvic 
peritonitis,  the  lower  temperature,  and  the  results  of  the  pelvic  ex- 
aminations are  usually  sufficient  to  establish  the  diagnosis  of  ectopic 
pregnancy.  After  rupture  has  occurred,  the  diagnosis  is  not  always 
so  easy;  however,  the  liistory  of  sudden  pain  in  the  ovarian  region, 
sometimes  occurring  after  a  slight  physical  effort,  followed  by  the 
symptoms  of  internal  hemorrhage,  combined  with  the  finding  of  free 
fluid  in  Douglas'  culdesac,  will  clear  up  the  diagnosis  in  most  cases. 
After  rupture  has  occurred  and  pelvic  peritonitis  has  set  in,  the  diag- 
nosis is  often  extremely  difficult.  A  careful  history  of  the  case  is 
of  great  value  in  these  cases.  Oastler-  has  directed  attention  to  the 
fact  that  in  cases  of  pelvic  inflammatory  disease  the  uterus  is  usually 
in  retroposition,  whereas  when  ectopic  pregnancy  is  present,  it  is  not 

'  Snegireff,  G.:  Monatsh.  f.  Geb.  u.  Gyn.,  July,  1912,  vol.  xxxvi,  Xo.  1. 
'  Oastler,  F.  R.:  Amer.  Jour.  Obst.,  January,  1913,  p.  158. 


i 


GONORRHEA   OF  THE   FALLOPIAN   TUBES  AND   OVARIES  271 

infrequently  in  anteposition.  When  the  ectopic  pregnane^'  is  ad- 
vanced, the  uterus  is  usuallj'  diverted  laterally  away  from  the  gesta- 
tion-sac. 

Pelvic  inflammatory  disease  of  pyogenic  origin  can  sometimes  not 
be  differentiated  from  the  gonorrheal  form.  In  general  the  former 
is  more  severe  and  acute,  and  almost  invariably  follows  the  emptying 
of  a  pregnant  uterus  or  intra-uterine  manipulations.  The  examina- 
tion of  these  cases  usually  reveals  a  marked  cellulitis  at  the  base  of  the 
broad  ligament,  whereas  the  tubes  may  be  but  little  or  not  at  all 
involved.  The  pyogenic  infections  arc  particularly  prone  to  produce 
ovarian  abscesses,  while  in  gonorrhea  suppurations  of  the  ovary  are 
usually  small,  somewhat  infrequent,  and  do  not  occur,  as  a  rule,  un- 
less the  disease  is  far  advanced.  In  gonococcal  cases,  therefore,  the 
induration  is  usually  at  a  somewhat  higher  level  in  the  pelvis,  and 
less  dense  than  when  the  infection  is  the  result  of  streptococci  or 
staphylococci.  In  the  latter  condition  uterine  bleeding  and  a  hard, 
almost  board-like  induration  at  the  base  of  the  broad  ligaments  are 
characteristic. 

Appendicitis  may  be  differentiated  from  gonorrheal  infection  by 
the  history,  the  location  of  the  pain,  and  by  the  fact  that  pelvic  ex- 
amination shows  that  the  uterus  and  appendages  are  normal.  It 
should  be  borne  in  mind  that  in  chronic  appendicitis  exacerbations  are 
especially  likely  to  occur  at  the  menstrual  period,  as  a  result  of  the 
congestion  that  occurs  at  this  time.  Morris'  asserts  that  when  the 
vermiform  appendix  is  at  fault,  a  hypersensitive  point,  one  and  one- 
half  inches  to  the  right  of  the  umbilicus,  is  usually  present,  whereas  if  the 
disorder  originates  in  the  pelvis,  a  corresponding  spot  of  tenderness  on 
the  opposite  side  will  be  present.  Actinomycosis  of  the  aj)pendages 
may  shimlate  gonorrhea  so  closely  that  only  a  careful  histologic  and 
bacteriologic  examination  will  make  differentiation  possible.  Actino- 
mycosis is,  however,  a  rare  disease,  and  is  generally  secondary  to  an 
infection  of  the  gastro-intestinal  tract,  which  usually  reaches  the 
uterine  appendages  by  perforation  and  direct  extension.  The  ai> 
pendages  are  the  seat  of  dense  connective-tissue  formation,  which 
often  leads  to  an  erroneous  diagnosis  of  tumor.  Not  infrequently 
the  actinomycotic  specimens  resemble  tuberculous  tubes.  These  fea- 
tures and  the  absence  of  gonorrhea  in  other  portions  of  the  genital 
tract  should,  in  most  cases,  establish  the  diagnosis.  The  evidence  of 
gonorrhea  in  the  lower  genital  tract  and  the  bacteriologic  demon- 
stration of  the  specific  microorganism  alwaj's  furnish  strong  presump- 
tive evidence  in  cases  in  which  inflannnatory  disease  is  suspected, 

'  Morris,  R.  T.:  Amer.  Jour.  Oljstct.,  100!),  vol.  Ix,  No.  2,  p.  570. 


272  GONORRHEA    IN   WOMEN 

although  it  should  be  remembered  that  gonorrhea  is  a  very  common 
disease  and  may,  therefore,  be  combined  with  other  pelvic  lesions. 
In  a  small  proportion  of  cases  confrontation  may  be  of  value.  In 
some  instances  even  the  most  skilful  diagnosticians  may  be  led  into 
error.  Vague  symptoms,  inability  of  the  patient  to  give  an  intelligent 
history,  the  absence  of  proper  facilities,  faulty  preparation  for  pelvic 
examination,  and,  finally,  and  perhaps  the  most  frequent  of  all  causes, 
atypical  cases,  are  all  conditions  that  militate  against  the  formulation 
of  a  correct  diagnosis. 

The  cases  of  gonorrheal  pelvic  inflammatory  disease  that  are  most 
likely  to  be  mistaken  for  some  of  the  foregoing  conditions  are  usually 
the  ones  in  which  immediate  operative  intervention  is  required.  Thus, 
torsion  or  rupture  of  inflammatory  adnexa  produces  symptoms, 
especially  if  upon  the  right  side,  which  closely  simulate  acute  ap- 
pendicitis, both  of  which  conditions  require  immediate  operative 
interference. 

The  greatest  gentleness  should  always  be  obser\'ed  when  examining 
cases  of  pelvic  inflammatory  disease  suspected  to  be  of  gonococcal 
origin,  for  rough  handling  may  cause  an  acute  exacerbation.  The 
more  acute  the  case  is,  the  greater  are  the  dangers  arising  from  trauma. 
Indeed,  a  slight  rise  of  temperature  following  a  pelvic  examination  is 
almost  characteristic  of  this  disease,  especially  if  the  lesions  are  sup- 
purative in  type. 

Prognosis. — Owing  to  the  great  variety  of  lesions  included  under 
the  term ' '  pelvic  inflammatory  disease ' '  (metritis,  salpingitis,  oophoritis, 
pelvic  peritonitis,  cellulitis,  lymphangitis,  and  parametritis),  the  ulti- 
mate outcome  of  untreated  cases  varies  widely  in  different  cases.  If  pus 
is  present,  the  abscess  may  rupture  into  the  general  peritoneal  cavity, 
setting  up  a  diffuse  or  a  local  peritonitis,  or,  in  rare  instances,  even 
a  general  septicemia.  The  result  of  intraperitoneal  rupture  depends 
largely  upon  the  virulence  of  the  infection  and  the  resistance  of  the 
patient.  (See  Chapter  XIII.)  The  abscess  may,  if  situated  low 
down  in  Douglas'  culdesac,  discharge  through  the  vagina,  and  leave 
behind  a  fistulous  tract,  or  it  may  rupture  into  the  intestine,  especially 
the  rectum,  and  produce  a  temporary  or  permanent  intestinal  fistula, 
the  pus  being  discharged  through  the  anus  and  not  infrequently 
causing  a  proctitis.  When  the  abscess  ruptures  into  the  intestine, 
this  usually  brings  about  a  temporary  cessation  of  symptoms,  and  in 
rare  instances  a  cure  may  in  this  way  be  established.  This  is  by  no 
means  an  uncommon  complication  in  neglected  cases.     Alexandre^ 


'  Alexandre:   Contribution   h.  I'etude  des   pyosalpinx   spontanement  ouvert  dans 
rectum,  1911,  Destout  Atne  et  Cie.,  Paris,  p.  60. 


I 


GONORRHEA    OF   THE    FALLOPIAN  TUBES   AND   OVARIES  273 

has  noted  this  condition  frequently.  If  a  proctitis  results,  the  infec- 
tion of  the  intestine  is  likely  to  be  extremely  chronic.  If  the  abscess 
lies  anterior  to  the  uterus,  it  may  burst  into  the  bladder  and  its  con- 
tents be  passed  through  the  urethra,  thus  .setting  up  a  cystitis. 
Cajal'  and  Kouchner-  have  reported  cases  of  this  condition.  In  rare 
instances  the  contents  of  the  inflammatory  adnexa  may  be  discharged 
into  the  uterine  cavity.  The  inflammatory  appendage  may  rupture 
and  discharge  its  contents  between  the  layers  of  the  broad  ligament,  and 
from  here  the  pus  may  burrow  downward  and  present  in  the  vagina,  or 
it  may  follow  the  course  of  the  round  ligament  and  point  in  the  in- 
guinal region.  In  very  exceptional  cases,  such  as  those  reported  by 
Veit^  and  by  Gaget,'*  pus  may  burrow  its  way  through  the  abdominal 
wall  and  in  this  way  produce  a  tubo-abdominal  fistula.  Rupture 
in  any  form  is  unusual.  A  pyosalpinx  maj'  be  converted  into  a  hydro- 
salpinx and  the  tubal  contents,  becoming  sterile,  ma}'  be  graduallj' 
partially  or  entirelj'  absorbed,  and  in  this  way  the  residuum  of  the 
disease  may  continue  for  years  without  producing  severe  symptoms. 
Menge^  and  others  refute,  on  histologic  grounds,  the  possibility  of  a 
pyosalpinx  ever  becoming  a  hydrosalpinx.  That  in  rare  instances 
the  contents  of  a  hydrosalpinx  maj'  become  purulent  is  conceded  by 
all  observers. 

Mild  cases,  especially  those  in  which  occlusion  of  the  tube  does  not 
take  place,  may  undergo  complete  resolution.  Bumm"  believes  that 
so  long  as  the  infection  is  confined  to  the  tubal  mucosa  a  complete 
cure  may  result,  but  if  the  disease  extends  beyond  this  point,  adhesions 
and  other  lesions  follow.  ]VIore  commonly,  however,  these  patients 
remain  semi-invalids  for  the  remainder  of  their  lives,  periods  of  quies- 
cence being  interspersed  with  acute  attacks  of  pelvic  peritonitis. 
Many  patients  l)ecome  neurasthenic.  The  onset  of  the  menopause  is 
often  followed  by  relief:  the  atrophy  of  the  mucosa  and  musculature 
of  the  genital  tract,  the  cessation  of  the  monthly  congestion  incident 
to  menstruation,  and  the  ending  of  the  sexual  life  of  the  individual 
all  tend  to  lessen  the  disease. 

'  Cajal,  P.  R.:  La  Cliniea  modcnia,  ,Iuly,  1912,  pp.  :iG3-:5t)7  and  401-408. 

'  Kouchner,  M.:   Vratchcbnaya  Gazeta,  April,  1912. 

'  Voit:   (2uotc<l  by  Cuin.ston:   Amcr.  Med.,  1902,  vol.  iv,  p.  fill. 

*  (iaget:   J.yon  med.,  1908,  vol.  cxi,  p.  978. 

'  Menge:   Cent.  f.  Gyn.,  189.5,  vol.  xix,  p.  799. 

•  Hiimin:  Therap.  d.  Gegcnwart,  1909,  N'o.  I,  p.  .51. 


CHAPTER  XIII 

THE  TREATMENT  OF  PELVIC  INFLAMMATORY  DISEASE 

It  is  now  well  recognized  that  operative  intervention  during  the 
acute  stage  of  gonorrheal  pelvic  inflammatory  disease  is  unwise  unless 
delay  would  endanger  the  life  of  the  patient  or  if  pus  is  present  and 
can  be  evacuated  without  traversing  the  peritoneal  cavity.  Gonor- 
rheal pelvic  inflammatory  disease,  unlike  similar  conditions  produced 
by  the  pyogenic  microorganism,  usually  tends  to  become  chronic, 
and  the  cases  in  which  delay  is  dangerous  to  the  life  of  the  patient  are 
exceptional.  The  greatest  advance  that  has  been  made  m  recent 
years  in  the  treatment  of  these  cases  is  the  adoption  of  the  waiting 
policy  advocated  by  Simpson.'  This  consists  of  keeping  the  patient 
in  bed,  the  judicious  use  of  mild  laxatives,  the  application  of  either 
cold  or  heat  to  the  lower  abdomen,  and  the  employment  of  frequent 
copious  vaginal  irrigations.  These  are  the  sheet-anchors  of  treat- 
ment during  the  acute  stage  of  gonorrheal  pelvic  inflanmiatory  disease. 
Various  other  methods,  some  of  which  are  subsequently  described, 
have  been  recommended,  but  the  value  of  many  of  them  has  not  as 
yet  been  positively  proved.  It  must  be  remembered  that  most  cases 
of  pelvic  inflammatory  disease  will  survive  the  acute  stage,  even  if 
left  entirely  alone.  Any  form  of  treatment  that  may  produce  trauma 
is  not  without  danger,  and  is  at  least  likely  to  prolong,  rather  than 
accelerate,  the  subsidence  of  the  disease. 

Hofmeier^  advises  against  all  forms  of  purgation,  and  depends 
solely  upon  enemata;  as  has  previously  been  stated,  enemata  given 
during  the  course  of  an  acute  gonorrhea  are  not  without  danger,  and, 
in  the  author's  opinion,  are  contraindicated  in  the  majority  of  cases. 
During  the  acute  stage  of  the  disease  liquid  diet  should  be  prescribed, 
and  as  the  acute  symptoms  begin  to  subside  a  light,  nourishing,  easily 
digested  diet,  free  from  alcohol,  should  be  ordered.  If,  during  the  acute 
stage,  any  doubt  exists  as  to  the  source  of  the  peritonitis,  all  solid 
food  by  mouth  should  be  withheld  until  this  point  is  cleared  up.  In 
this  connection  it  should  be  remembered  that  during  the  acute  stage 
some  cases  of  pelvic  peritonitis  closely  simulate  appendicitis,  and  for 

■  Simpson:  Jour.  Amer.  Med.  Assoc,  1909,  No.  1"),  vol.  liii,  11.  117"). 

=  Hofmeier:   Dculsch.  mt'd.  Wophenschr.,  1909,  vol.  xxxv,  p.  2249. 

274 


THE    TREATMEXT    OF    PELVIC    INFLAMMATORY    DISEASE  275 

this  reason  every  caution  should  be  adopted.  Pelvic  examinations 
should  be  as  limited  in  number  as  possible,  and  should  be  gently  pe! 
formed,  as  the  dangers  to  the  patient  from  trauma  are  very  grel 
Cold  by  means  of  ice-bags  or  ice-coils  should  be  applied  to  thefower 
abdomen  and  frequent  copious  cold  douches  administered  Hofmeie,  ' 
Bumm,-  and  Freund'^  are  strong  advocates  of  this  treatment 

As  the  acute  symptoms  begin  to  subside  the  application  of  heat 
to  the  lower  abdomen,  together  with  the  frequent  use  of  copious 
hot  vagina  douches,  is  of  great  benefit.     Heat  may  be  applied  in  the 

hecomfoit  of  the  individual  patient;  or  large  hot  poultices,  rubber 
oils  contaim,^-  hot  water,  or  a  hot-water  bag  may  be  employed 
n  any  case  the  heat  should  be  applied  as  constantly  as  possible    a 

temperature  of  110°  to  120°  F.  being  maintained.  1  good  worW^g 
ule  m  this  respect  is  to  have  the  application  as  hot  a.f  can  be  c<^^' 

fortably  borne  by  the  patient.     Alexandron^  is  strongly  of  the  op  n- 

cold  IS  preferable  for  purposes  of  stimulation.  The  majority  of  the 
German  authorities  apply  cold  during  the  acute  state  and  hea 
VNhen  the  symptoms  become  subacute  or  chronic,  the  heat  frequently 
being  applied  by  means  of  hot  air,  in  the  manner  described  in  a 
previous  chapter.  Sieber^  employs  a  modified  hot-air  apparatus  tha't 
provides  a  constant  current  of  varying  temperatures,  as  demanded 
by  the  m.hvKlual  case.  The  apparatus  consists  of  a  series  of  ubullr 
celluloid  specula  which  may  be  connected  with  an  electric  heatt^ 
apparatus  in  such  a  manner  that  a  current  of  hot  air  can  be  delivered 
at  the  end  of  the  speculum  without  unduly  heating  the  latter  \ 
temperature  of  200°  ( '.  can  be  generated.     Sieber  has  usee    tie  ap 

pamtus  with  success  m  a  large  , ,ber  of  cases  in  which  pelvic  e     - 

dates  were  present. 

Alternate  hot  and  cold  applications  are  recommended  by  Proch- 

ownick,    who  advises  the  application,   firs,,  of  ice  to  the  abdomen 
^owodbymoistheat,  and  finally   ho,   air  i^^ 

I'M.    baths  so  arranged  that  ,he  hea,  can  gra.luallv  be  increased        \s 

re^luUon   occurs, I,,.  .,,na,ion    of   ,1.    ho.-air   ba.hs   is   leng,lH.ne<l. 

^I'Tf  ''"•"•';"^' ;■"-'-'"■'«  "'•  """  and  one-half  gallons  of  sterile 

«at(,  o,  o,  norn.al  sal,  >nln,i.,n,  should  he  adnunis.ered  two  or  three 

'  llnlrMchT;    l),.,iiscli.  i,u;l.  \\  „,.|,.,  |..hmi,  .\„.  ;j.-,    p    •>.,.,,, 
■  Hurmn,  K.:   'l'li,.r:,[,.  ,1.  C.VKruxy..  I'.KV.I,  \„    1    ,',  ,-,i 
;  Kr-..n,l    H.:  Th.-n,,..  .Monalsl,.,  .M.-url,,  1!,1I,  vol,  xxv,  X,,.  :{,  „    ,.57 
^Al,.x;w..lr.m:   Mo.mts.  f.  (:,.|,.  „.(;,.„„  vol.  xii,  ,,.  inr,.  ' 

N.-Imt:   .MiincI,,  m<..|.  Wocl...  .Janiii.rv  .«),  11112 
IVorhownirk,  I..:    Mo>m.s.  f.  ( ;,.|,.  „.  (Iv,,  ,  l-H)!!,  \o    -I   ,,   Vyi 


276  GONORRHEA    IN    WOMEN 

times  daily.  In  these  cases  small  douches  are  of  little  value;  indeed, 
Richeloti  states  that  as  much  as  20  gallons  should  be  employed.  If 
the  discharge  is  profuse,  the  douche  may  be  preceded  by  an  irrigation 
with  a  quart  of  hot  water  to  which  a  dram  of  A.  B.  C.  douche  powder 
or  other  mild  antiseptic  has  been  added.  It  is  important  that  the 
douche  be  given  slowly  and  that  no  force  be  used.  It  will  usually  be 
found  that  the  much  hotter  fluid  may  be  employed  if  the  temperature 
is  raised  gradually  than  if  very  hot  water  is  used  at  the  beginning. 
The  same  caution  should  be  employed  in  the  administration  of  these 
douches  as  has  been  described  under  the  treatment  of  acute  metritis. 
If  the  pain  is  very  severe  and  is  not  relieved  by  the  application  of 
either  heat  or  cold,  the  administration  of  some  one  of  the  opium 
derivatives  may  become  necessary,  but  these  should  be  exhibited  as 
sparingly  as  possible.  Schindler-  contends  that  to  account  for  the 
large  proportion  of  gonorrheal  infections  above  the  cervix  the  uterus 
must  possess  some  active  movements,  the  gonococcus,  as  is  well  known, 
being  non-motile.  This  observer  believes  these  movements  are  invol- 
untary and  not  influenced  by  the  central  nervous  sj^stem.  The 
administration  of  atropin  paralyzes  the  automatic  movements,  and 
for  this  reason  he  recommends  its  use  during  the  acute  stage  of  all 
gonorrheal  infections. 

During  the  acute  stage  the  placing  of  the  patient  in  the  upright 
Fowler  position  is  of  great  advantage,  not  only  for  the  treatment  of 
the  peritonitis,  but  it  helps  very  materially  in  draining  the  uterus, 
which  is  usually  the  seat  of  an  endometritis  or  a  metritis.  In  cases 
that  present  unusually  severe  symptoms  of  pelvic  peritonitis  entero- 
clysis,  as  suggested  by  Murphy,  may  be  employed  with  advantage. 
To  guard  against  infection  of  the  rectum  the  perineum  and  external 
genitalia  should  be  thoroughly  wiped  with  absorbent  cotton  soake(^  I 
in  1 :  1000  bichlorid  solution.  A  tampon  should  be  inserted  in  tha 
vagina  before  the  rectal  tube  is  introduced.  Additional  medicina 
treatment  is  rarely  indicated. 

The  advantages  to  be  derived  from  the  pallia  ti\-e  treatment 
over  immediate  operative  intervention  are  manifold.  In  itself,  gon- 
orrhea is  rarely  a  fatal  disease.  The  results  of  this  plan  of  treatment 
are  generally  most  satisfactory.  Large,  painful  tubes  resolve  them- 
selves into  small  adherent  organs,  the  ovarian  symptoms  tend  to 
subside,  and  tender,  adherent  masses  finally  disappear,  ^\1lile  sur- 
gical intervention  is  not  indicated  in  the  great  majority  of  cases  ol 
acute  gonorrheal  pelvic  inflammatory  disease,  nevertheless  the  patients 

'  Richelot:  La  Gyn^cologie,  May,  1909. 

-  Schindler,  C:  Arch.  f.  Gyn.,  BerUn,  1909,  vol.  Ixxxvii,  p.  607. 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  277 

are  essentially  surgical  subjects  and  should  be  carefully  guarded,  as 
complications  may  arise  that  will  demand  immediate  operation.  If 
pus  forms  and  can  be  evacuated  without  danger  of  infecting  the 
peritoneal  cavit}',  this  should  be  done  at  once,  and  in  these  cases 
the  incision  should  be  a  large  one — at  least  5  to  8  cm.  in  length. 
Boldt'  recommends  an  incision  large  enough  to  admit  the  hand. 
With  the  rare  exception  of  rupture  or  torsion  of  an  inflamed  uterine 
appendage  or  the  development  of  general  peritonitis,  these  are  prac- 
tically the  only  indications  for  operative  intervention  during  the  acute 
stage. 

Kuhn-  suggests  the  treatment  of  pelvic  inflammatory  diseases 
with  injections  of  normal  salt  solution  into  the  rectum.  His  plan 
differs  from  the  ^Nlurphy-Ochsner  method.  Kuhn  suggests  that  the 
rectum  be  distended  at  six-hour  intervals  with  from  1  to  4  pints  of  the 
solution  at  a  temperature  of  105°  F.,  increasing  the  quantity  gradually 
as  tolerance  to  the  larger  amount  is  established.  He  claims  for  the 
method  that  it  produces  hyperemia,  hastens  the  destruction  of  the 
infecting  organi.sms,  induces  absorption,  prevents  the  formation  of 
adhesions,  stimulates  the  emunctories,  and  relieves  pain.  The 
method  can  hardly  be  recommended,  at  least  as  a  routine  procedure, 
as  the  discomfort  caused  to  the  patient  is  considerable  and  the  dangers 
of  infection  of  the  rectum  are  great.  Unless  the  treatment  is  applied 
with  the  utmost  care,  the  danger  from  overdistention  of  the  rectum 
and  the  possibility  of  lighting  up  a  chronic  inflammatory  disease  by 
the  trauma  incident  to  the  distention,  are  to  be  feared.  Flatau'  rec- 
ommends applying  heat  by  means  of  the  "pelvitherm"  (Heinroth 
Slanger,  Ulm  a.D.,  Germany),  which  raises  the  temperature  in  the 
female  pelvis  to  about  40°  C.  (104°  F.).  Cheron'  recommends  the 
use  of  radium  in  the  treatment  of  chronic  adnexitis  and  peri-adnexitis, 
on  account  of  its  atrophic  action  on  the  ovaries.  The  treatment  lasts 
from  one  to  six  weeks.  This  author  believes  that  radium  therapy 
alone  will  cure  many  cases,  and  that  it  is  an  excellent  preliminary  to, 
and  adjunct  in,  the  treatment  of  most  cases  in  which  surgical  inter- 
vention is  necessary.  The  radium  is  applied  in  silver  tubes  0.5  mm. 
in  diameter.  These  are  introduced  into  the  uterine  cavity  under 
a.septic  precautions.  Fabre'  asserts  that  radium  gi\-os  marked  relief 
froni  pain  and  frecjucntly  softens  indurated  areas  of  cellulitis.     Coni- 

'  Uoldl,  II.  .1.:  .Jour.  .Vmcr.  Mori.  .V.ssoc,  July  1:5,  1912,  p.  l():i. 
'  Kuhn,  J.  !■'.:  Texas  State  .lour.  .Mod.,  December,  1911,  vol.  vii,  No.  S, 
•  Flatau,  S.:   Munch,  raeil.  Woch.,  1900,  No.  2. 

*('heron,  II.:  Hi-v.  mens,  de  gj-ii.  d'obst.  et  do  paed.,  December,  1911;  also  La  Ob- 
8t6trif(ue,  .November,  1909. 

'  Fabre:  .\rcli.  Roentgen  Kays,  November,  1910,  p.  228. 


278  GONORRHEA    IN    WOMEN 

plete  cures  usually  require  prolonged  treatment.  Jacobs'  and  Bar- 
cat-  also  recommend  this  form  of  treatment  in  the  chronic  stage  of 
pelvic  inflammatory  disease.  The  last-named  author's  paper  con- 
tains a  review  of  the  recent  literature  on  this  subject.  Menge^  men- 
tions that  in  the  Heidelberg  Gynecological  Clinic  old  gonorrheal 
adnexitis  cases  that  are  complicated  by  profuse  bleeding  and  dis- 
charge are  treated  with  the  x-ray.  The  belief  of  some  authors  that 
this  treatment  will  cause  an  exacerbation  of  the  infection  is  com- 
bated by  Menge,  who  reports  excellent  results  from  its  employment. 

As  the  acute  symptoms  subside  hot  salt  sitz-baths  or  hot  general 
baths  can  often  be  given  with  advantage.  Freund^  has  shown  that 
when  hot  sitz-baths  are  given,  the  vaginal  temperature  is  often  raised 
as  much  as  5°  to  10°  F.  At  this  stage  Prochownick"  and  others  rec- 
ommend the  use  of  the  mercury  colpeurynter.  This  is  left  in  place 
at  first  for  two  or  three  hours  daily.  The  period  of  retention  is  grad- 
ually increased,  as  is  the  size  of  the  colpeurynter,  and  toward  the 
latter  stages  of  the  treatment  the  instrument  can  usually  be  retained 
without  discomfort  overnight.  A  hard-rubber  cylinder  has  some- 
times been  substituted  for  the  colpeurynter.  At  this  stage  Hofmeier* 
applies  heat  by  means  of  a  thermophile.  Sellheim^  applies  heat  by 
means  of  an  electric  current,  one  electrode  being  placed  over  the 
lower  abdomen  and  the  other  in  the  vagina,  the  pelvic  temperature 
being  raised  to  about  40°  or  41°  C.  (104°-105°  F).  This  produces 
first  a  hyperemia,  then  an  anemia,  and  finally  a  cyanosis  of  the  vaginal 
mucous  membfane.  This  writer  prefers  this  method  of  applying  heat, 
for  by  its  employment  it  is  possible  accurately  to  measure  and  control 
the  heat.  The  author  believes  that  the  indiscriminate  application  of 
electricity  to  cases  of  pelvic  inflammatory  disease  is  not  without 
danger,  as  is  instanced  by  the  case  of  rupture  of  a  pyosalpinx  during 
such  treatment  reported  by  Fisher.* 

Freund'  recommends  congestion  of  the  pelvic  organs,  as  advocated 
by  Bier,'"  the  suction  apparatus  being  placed  over  the  lower  abdomen. 
He  also  has  the  patients  assume  the  knee-chest  posture  for  ten  minutes 
twice  daily,  having  found  that  this  treatment  lowers  the  temperature 

'  Jacob.?:   La  Radium  en  Gynecologie,  1911. 

=  Barcat:   Prec6s  de  radium  therapio,  Paris,  1912. 

'  Menge,  K.:  Hand.  d.  Geschlechtskrankheiten,  Vicima,  1910. 

■"  Freund,  H.:  Therap.  Monatsh.,  March,  1911,  vol.  xxv,  No.  3,  p.  l.'J". 

'  Prochowniek,  L.:  Monats.  f.  Geb.  u.  Gyn.,  1909,  vol.  xxix,  p.  45.3. 

'  Hofmeier:   Deutsch.  med.  Woch.,  1909,  No.  35,  p.  2249. 

'  Sellheim:  Monats.  f.  Geb.  u.  Gyn.,  May,  1909,  vol.  xxxi,  p.  92. 

«  Fisher,  .1.  M.:  Trans.  Phila.  Obstet.  Soc,  1911. 

»  Freund,  H.:  Therap.  Monatsh.,  March,  1911,  vol.  xxv,  No.  3,  p.  157. 

'"  Bier:   Hyperamie  als  Heilmittel,  fifth  edition,  1907. 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  279 

of  the  vagina  4°  to  7°  F.  and  sometimes  more.  This  position  also  tends 
to  prevent  the  occurrence  of  extreme  retrodisplacement  of  the  uterus. 
While  the  patients  are  in  bed,  and  after  the  disappearance  of  the  fever, 
general  massage  is  beneficial,  but  care  must  be  taken  that  no  trauma 
is  inflicted  on  the  abdomen.  For  this  reason  the  massage  should  be 
administered  only  by  a  skilled  and  specially  instructed  attendant. 

After  about  the  second  or  third  week,  when  the  temperature  and 
pulse  are  normal,  it-  is  usually  advisable  to  get  the  patient  out  of  bed 
and  into  the  open  air.  Indeed,  when  pos.sible,  marked  improvement 
is  usually  shown,  even  in  bed  patients,  when  they  can  be  kept  in  the 
open  air,  and  it  seems  probable  that  this  adjunct  to  the  treatment  of 
pelvic  inflammatory  disease  has  been  much  neglected  in  the  past. 
Stone'  and  Young  and  Williams-  have  strongly  recommended  this 
form  of  treatment.  These  writers  state  that,  by  this  means,  their 
mortality  in  severe  cases  of  puerperal  sepsis  have  been  reduced  nearly 
20  per  cent.  They  believe  that  sunlight  is  nearly  as  important  as 
fresh  air,  and  think  that  the  open-air  treatment  is  beneficial  largely 
because  of  the  fact  that  it  quickly  increases  the  amount  of  hemoglobin. 
Watkins^  is  a  firm  believer  in  this  mode  of  treatment.  The  author's 
experience  has  been  that  patients  do  far  better  in  the  open  air  than 
when  confined  to  a  room  or  ward,,  no  matter  how  well  ventilated  the 
latter  maj-  be.  Yan  Oordt^  has  demonstrated,  by  his  extensive  ex- 
periments, that  patients  who  are  exposed  to  low  temperatures,  either 
in  a  nude  state  or  scantily  clothed,  show  a  leukocytosis  that  is  pro- 
duced by  thermotaxis.  The  leukocytosis  lasts  as  long  as  the  exposure 
to  cold  is  continued.  Lenkei''  found  that  in  his  researches  cold  air 
produced  a  9.S  per  cent,  increase  of  leukocytes.  Orr,"  however,  found 
that  in  afebrile  patients  in  whom  the  face  only  was  exposed  there  was 
no  constant  change  in  the  leukocytes. 

The  general  plan  of  treatment  should  be  a  building-up  and  strength- 
ening process.  Mild  laxatives  and  tonics  containing  iron  or  arsenic 
may  be  indicated.  All  exercise  should  be  restricted,  and  sexual  inter- 
course interdicted.  The  dangers  of  reinfection  from  a  husband  who 
has  an  uncured  gonorrhea  and  of  trauma  incident  to  coitus  are  very 
real  and  ha\'e  been  extensi\ely  dwelt  upon  by  Boldt"  in  a  recent  article. 

'  Si.iiic-:   Mill.  I^oronl.  1907.  vol.  Ixxi,  p.  L'Ki. 

•  VouiiK.  K.  H.,  an.l  Williams,  .1.  'I'.:  H.isloii  Mc.l,  uii.l  Siirn  .Imir..  Man-I,  11,  I'.tl.', 
p.  4().V 

'  Wat  kins,  T.  J.:    Personal  coinmiinicatioii. 

'Van  f)or<lt:   Zcit.  f.  (liiilotisclio  ii.  phy.sikali.schr  'I'licrapic  1<.H).')-(1(;,  vol.  i\,  p.  :i:{S. 

'  Lcnkoi:    Vrsicr  riicil.  Cliir.,  May,  1910,  vol.  xlvi,  No.  20. 

•  Orr,  T.  (;.:   Amcr.  .lour.  .Med.  Sci.,  AukusI,  1912,  p.  2:«. 

'  Holdl,  H.  .!.:  .lour.  Amcr.  .Med.  A.ssoc.  .luly  Kl,  1912,  p.  100. 


280  GONORRHEA    IN    WOMEN 

The  douches  should  bo  continued,  and  local  treatment,  consisting  of  the 
insertion  of  a  vaginal  tampon  saturated  with  ichthyol  or  glycerin,  or  one 
of  the  other  remedies  recommended  in  the  treatment  of  metritis,  should 
be  applied  once  or  twice  a  week.  The  tampon  should  be  left  in  place 
for  from  ten  to  sixteen  hours,  and  on  its  withdrawal  a  hot  vaginal  irriga- 
tion should  be  given.  On  the  days  when  the  tampons  are  inserted  all 
other  forms  of  local  treatment  should  be  discontinued.  If,  during  the 
course  of  this  treatment,  the  temperature  rises  to  100°  F.,  or  other 
symptoms  indicative  of  a  recurrence  of  the  acute  condition  appear, 
the  patient  should  return  to  bed  and  the  treatment  previously  out- 
lined for  the  acute  stage  of  the  disease  administered.  During  the 
course  of  the  palliative  treatment  it  is  of  the  utmost  importance  that 
all  local  measures  be  applied  with  great  gentleness,  as  trauma  at  this 
stage  is  likely  to  light  up  the  acute  condition. 

With  the  palliative  method  of  treatment  a  certain  percentage  of 
cases  will  be  spared  any  form  of  operative  intervention.  Before 
entering  into  a  discussion  of  the  permanent  efficiency  of  this  treat- 
ment, however,  it  is  important  first  to  define  what  is  meant  by  a  cure, 
as  a  complete  anatomic  cure  is,  in  the  majority  of  cases,  impossible. 
In  this  connection  Prochownick^  states  that  when  a  cure  is  permanent 
the  patient  must  be  able  to  take  up  her  mode  of  life  or  occupation; 
her  sexual  organs  and  the  neighboring  intestines  must  functionate 
regularly  and  painlessly.  Prochownick's  statistics  are  of  particular 
value;  his  hospital  is  so  richly  endowed  that  patients  are  allowed  to 
remain  indefinitely,  and,  if  necessary,  they  are  sent  to  the  seashore- 
at  the  hospital's  expense.  In  compiling  his  statistics  he  has  included 
no  cases  that  have  been  treated  later  than  1905,  so  that  it  may  be 
inferred  that  all  recurrences  have  been  noted.  It  is,  of  course,  im- 
possible in  this  connection  positively  to  exclude  all  forms  of  infection 
other  than  gonorrheal.  In  Prochownick's  series  no  tuberculous  cases 
are  admitted.  He,  however,  includes  in  his  list  of  cases  receiving 
palliative  treatment  those  in  which  pus  collections  in  either  the  tubes 
or  the  ovaries  were  evacuated  extraperitoneally,  and  in  which  no 
organs  were  removed.  Of  420  cases,  160,  or  38  per  cent.,  were  per- 
manent cures.  Of  these,  70  per  cent,  were  treated  for  not  less  than 
four  weeks,  whereas  many  were  treated  for  five  or  six  weeks  in  the 
hosiptal  and  were  then  sent  to  a  sanatorium  for  three  or  four  weeks 
more.  Of  the  160  cases,  10  per  cent,  had  pus  collections  which  were 
evacuated,  and  these  usually  required  treatment  for  two  or  three 
weeks  longer  than  those  in  which  no  operation  was  necessary.  Of  the 
160  cases,  85,  or  55  per  cent.,  remained  well  after  one  course  of  treat- 
'  Prochownick,  L.:    Monats.  f.  Gfb.  u.  Gyn.,  1909,  No.  20,  p.  453. 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  281 

nient.  Of  this  number  14  subsequenth'  gave  birth  to  children  and 
3  aborted.  After  a  second  course  of  treatment  27  remained  well  and 
3  became  pregnant,  of  which  1  aborted.  In  other  words,  1  in  every 
8  cases  cured  became  pregnant.  In  this  connection  it  should  be  re- 
membered that  many  of  these  patients  were  not  married  and  that 
others  were  not  young,  so  that  if  the  statistics  covered  only  those 
patients  in  which  impregnation  was  likely  to  occur,  the  proportion 
would  probably  be  much  higher.  Of  these  160  cases  10  finally  re- 
quired operation  for  relief  of  adhesions,  but  it  was  not  necessary, 
however,  to  remove  any  organs.  These  10  operations  occurred  at 
varying  intervals  of  from  three  to  five  years  after  the  first  treatment. 
One  of  these  patients  subsequently  gave  birth  to  a  child.  The  number 
of  permanent  cures  without  any  operative  interference  whatever  was 
80,  or  19  per  cent.,  of  420  cases.  In  Prochownick's  series  of  cases  no 
deaths  resulted  from  the  palliative  treatment.  In  contradistinction 
to  the  foregoing  statistics,  Henkel'  states  that  in  from  80  to  90  per 
cent,  of  all  inflammatory  affections  of  the  adnexa  "subjective  healing" 
occurs  following  judicious  non-operative  treatment.  Olshausen-  is 
a  firm  believer  in  the  palliative  treatment,  and  in  his  clinic  operations 
on  inflamed  adnexa  arc,  if  possible,  deferred  until  nine  months  after 
the  occurrence  of  the  infection,-  and  are  then  performed  when  the 
temperature  is  normal. 

Ooth^  has  recently  reported  excellent  results  in  a  series  of  700 
cases  of  pelvic  inflammatory  disease  treated  by  the  palliative  method 
in  Szabo's  clinic.  The  treatment  consisted  in  i-est  in  bed,  the  applica- 
tion of  ice-bags  over  the  lower  abdomen,  and  (•(i])ious  vaginal  irriga- 
tions of  cold  sterile  water — at  a  temperature  of  10°  or  11°  C.  (50°  to 
51°  F.) — during  the  acute  stage.  As  soon  as  the  temperature  and 
pulse  became  normal  and  the  pnin  had  subsided  hot  applications  were 
substituted  for  the  cold,  ;iii(l  tampons  containing  from  10  to  20  per 
cent,  ichthj'ol  were  introdiiced  two  or  three  times  a  week.  When 
the  presence  of  gonococci  could  be  demonstrated  in  the  discharge, 
I)r()targoI  in  20  per  cent,  solution  was  employed  in  place  of  the  ichthyol. 
Pelvic  examinations  wei'c  made  once  a  week.  Preparations  of  iron 
were  employed  as  tonics,  and  morphin  was  given  to  control  ])ain  and 
ergotin  to  check  bleeding.  The  cures  consumed  on  an  average  fifty- 
six  days,  the  minimum  being  eighteen  days,  and  the  maximum,  two 
hundred  and  thirty  days,  (loth  believes  that  febrile  cases  respond 
more  readily  than  afebrile  ones  to  treatment. 

'  llcnkcl:  (2iioH-(l  by  Kscli:  Zi-it.  f.  (iel).  u.  (iyn-,  Ii»l)7,  vol.  lix,  No.  I. 
■  OlNhaiiscn:  Quoted  l>y  Kseh:  Zcit.  f.  Gcb.  ii.  (iyn.,  li)07,  vol.  lix,  .No.  1. 
Mlolh:   Anil.  f.  Cyn.,  vol.  .\cii,  No.  2,  \>.  :5()0. 


282  GONORRHEA    IN    WOMEN 

De  Rouville'  reports  the  results  obtained  in  a  series  of  40  cases 
treated  by  the  palhative  treatment.  Of  these,  32  were  cured  and  3 
subsequently  became  pregnant.  Ciriffith-  reports  the  results  obtained 
by  the  palliative  treatment  in  48  cases.  No  deaths  occurred,  and 
the  local  conditions  were  much  improved.  Topfer^  strongly  urges 
palliative  treatment  in  these  cases. 

The  chief  difficulty  attendant  upon  the  form  of  treatment  just 
outlined  is  the  amount  of  time  that  is  required.  During  the  acute 
stage  the  patient  should  certainly  be  in  a  hospital.  After  two  or 
three  weeks  the  condition  is  generally  such  that  the  remainder  of  the 
treatment  can  be  carried  out  in  the  home,  under  the  supervision  of 
the  family  physician.  Before  such  patients  are  discharged  from  the 
hospital  they  should  be  informed  of  the  nature  and  probable  course 
of  their  disease,  and  a  careful  bimanual  examination  should  be  made 
in  order  to  ascertain  the  exact  pelvic  condition.  They  should  be 
instructed  regarding  their  mode  of  life  and  the  importance  of  treat- 
ment; sexual  intercourse  should  be  interdicted.  Whenever  possible, 
the  entire  course  of  treatment  is  best  carried  out  in  a  hospital  or  sana- 
torium, for  in  spite  of  the  most  careful  instructions,  these  patients, 
when  at  home,  after  the  pain  has  subsided  frequently  commit  in- 
discretions in  diet,  neglect  their  treatment,  or  indulge  in  sexual  inter- 
course, oftentimes  with  a  chronically  infected  husband,  and  as  a 
result,  relapses  occur.  The  patient's  social  status  is  of  importance  in 
this  connection.  As  has  been  pointed  out  by  de  Rouville,''  women 
who  have  to  work  hard  are  more  prone  to  develop  a  recurrence  after 
palliative  treatment  than  are  their  more  well-to-do  sisters. 

The  author  believes  that,  in  spite  of  any  form  of  palliative  treat- 
ment that  may  be  adopted,  the  majority  of  gonococcal  inflammations 
of  the  appendages  will  ultimately  require  operative  intervention; 
nevertheless,  he  is  of  the  opinion  that  a  fair  trial  of  such  treatment 
should  be  made  in  each  case,  and  that  by  this  method  better  operative 
results  will  be  obtained  than  if  immediate  operation  were  undertaken. 
Under  the  palhative  treatment  the  infective  microorganisms  in  many 
cases  become  innocuous,  and  the  uterus  and  adnexa  again  approach 
the  normal.  Nature  has  been  allowed  to  cure  as  much  of  the  pathology 
as  possible,  and  when  the  abdomen  is  opened,  one  can  more  easily 
decide  upon  the  most  suitable  operation  for  the  individual  case.  There 
can  be  no  doubt  that  following  the  expectant  treatment  a  greater 

'  lie  Rouville;   Annal.  de  Gyn.  et  d'Obst.,  (Jctobor,  1910. 

2  Griffith,  W.  S.  A.:   Brit.  Med.  Jour.,  October  26,  1912,  p.  llOli. 

'Topfor:   Rerlin.  klin.  Woch.,  September  2,  1912. 

»  de  Kouvillc:   Annal.  de  Gyn.  et  d'Obst.,  October,  1910. 


I 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  283 

number  of  cases  will  be  rendered  suitable  for  conser^•ative  operations 
than  if  they  were  at  once  subjected  to  surgical  treatment  during  the 
acute  stage.  Furthermore,  the  mortality  will  be  reduced.  Following 
this  plan  Simpson'  has  reported  475  consecutive  abdominal  sections 
for  inflammatorj'  lesions  of  tubal  origin,  with  only  4  deaths.  In 
addition  to  the  reduced  mortality,  the  postoperative  results  will  be 
improved.  It  will  be  found  that  the  operation  can  be  performed  with 
greater  speed  and  less  anesthetic  will  be  required,  and  fewer  hernias 
and  a  lessened  proportion  of  operative  infections  and  consequent 
postoperative  adhesions  will  be  encountered. 

By  converting  acute  inflammatory  infections  of  pelvic  origin  into 
aseptic  lesions  the  mortality  will  be  reduced  and  the  postoperative  re- 
sults vastly  improved.  Undoubtedly,  occasionally  cases  will  be  en- 
countered that  will  not  improve  under  expectant  treatment,  but  the 
more  carefully  these  cases  are  studied,  the  fewer  will  be  the  number 
requiring  immediate  operative  intervention.  Sanger,  the  skilled  pa- 
thologist and  gynecologist  par  excellence,  was  the  first  to  lay  stress 
on  the  fact  that  chronically  adherent  appendages  were  not  the  seat  of 
infection,  but  merely  the  derelicts  of  the  gonococcal  storm.  Accuracy 
of  diagnosis  is  the  necessary  adjunct  to  this  treatment,  and  only  by 
its  aid  can  the  surgeon  successfully  adopt  the  waiting  policy.  Bumm- 
is  of  the  opinion  that  the  majority  of  cases  of  postoperative  peritonitis 
result  from  too  earh'  operation.  He  thinks  it  best  to  wait  until  the 
infection  becomes  localized,  as  sometimes  there  is  a  mixed  infection, 
and  early  operation  on  such  cases  frequently  results  in  fatal  perito- 
nitis. Thaler,''  after  having  reviewed  6179  cases  of  jjelvic  inflammatory 
disease  at  Schauta's  clinic,  concludes  that  operative  treatment  is  indi- 
cated only  after  palliative  treatment  has  failed,  except  in  cases  where 
it  is  necessary  to  evacuate  pus. 

.Vuihorn'  reports  an  interesting  series  of  treatments  from  Zweifel's 
clinic.  In  123  cases  of  adnexitis  that  were  chiefly  gonococcal  in 
type,  and  that  varied  in  degree  from  slight  inflammations  to  large 
tubal  abscesses,  he  injected  silver  solutions  into  the  uterine  cavity. 
Some  years  previously  Zweifel  had  carried  out  a  series  of  experiments 
which  consisted  of  the  injection  of  methylene-blue  solution  into  the 
uterine  cavity,  and  found  that  in  every  case  the  blue  was  carried  out 
into   the   tubes.'     Aulhorn'-s"  treatment  consisted   of   the   following: 

'  Simpson:  .Jour.  .\mer.  Mfd.  .A.s.soc,  li)()9.  No.  1.'),  vol.  liii,  p.  117.') 

'  Humin:  Tlicnip.  li.  (Icgcrivvart.  1909,  No.  1,  p.  .")1. 

'Thaler,  II.:   Arcli,  f.  Cyn.,  Horliii.  vol.  xciii,  No.  :{,  p.  ll.i. 

'  .\iilliorn:  .\rcli.  f.  (!yii.,  vol.  xv.  No.  2,  p.  2i:i. 

'In  II  oasos,  S  of  which  were  inflamiiialory  and  in  .'J  of  which  the-  luhc.-i  were  normal, 
I  he  author  ha.s  injected  either  met  hyleiic-hlue  or  .starch  solution  into  the  uterine  cavity. 
In  tione  ha.s  it  been  pos.sihic  to  clerri'oM.-tnitc  llic  iTi:ileri:il  In  the  lulics. 

'■  .Vuihorn:   A,or.  rii. 


284  GONORRHEA    IN    WOMEN 

No  injections  were  made  during  the  acute  stage.  The  patients  were 
kept  in  bed.  The  injections  were  made  up  of  a  colloidal  silver,  such 
as  argentamin,  or  a  silver  phosphate,  often  ethylendiamin,  in  2  per 
cent,  solution.  One  or  1.5  c.c.  was  injected  at  the  first  treatment. 
At  subsequent  treatments  this  amount  was  increased  to  2.5  c.c.  The 
treatments  were  given  6  times  a  week.  At  first  considerable  pain 
followed  the  injections.  This  lasted  for  one  or  two  hours.  Of  123 
cases,  108,  or  88  per  cent.,  were  cured  of  all  symptoms,  7  improved, 
whereas  in  8  little  or  no  benefit  was  derived.  Examined  objectively, 
a  cure  was  effected  in  89,  or  72  per  cent.,  marked  improvement  in  16, 
and  little  or  no  imj^rovement  in  18.  Before  treatment,  60  of  these 
cases  had  palpable  tubal  abscesses  the  size  of  a  hen's  egg  or  larger; 
46  of  these  were  objectively  cured.  Cures  required  from  15  to  40  in- 
jections, and  extended  over  a  period  of  from  four  to  six  weeks.  During 
the  course  of  treatment  many  cases  suffered  from  menorrhagia.  All 
treatments  were  discontinued  during  menstruation.  Aulhorn^  has 
employed  intra-uterine  injections  over  3500  times,  and  has  never  seen 
a  case  in  which  ill  effects  resulted.  The  author  is  of  the  opinion  that 
this  form  of  treatment  requires  more  confirmatory  experiments  be- 
fore its  adoption  could  be  generally  recommended,  and  that  it  is 
quite  probable  Aulhorn's  results  would  have  been  quite  as  good  if  no 
intra-uterine  injections  had  been  given. 

THE  TIME  TO  OPERATE  ON  CASES  OF  PELVIC  PERITONITIS 
Not  infrequently  cases  are  seen  in  which  the  question  arises  as 
to  whether  a  hysterectomy  and  a  bilateral  salpingo-oophorectomy 
shall  be  done  and  the  patient  relieved  of  her  present  trouble,  or  whether 
it  is  advisable  to  perform  one  of  the  conservative  operations.  To  de- 
cide this  question  many  factors  must  be  taken  into  consideration — 
the  age  of  the  patient,  whether  she  has  a  number  of  children,  whether 
she  is  particularly  desirous  of  maternity,  whether  she  has  to  support 
herself  by  hard  manual  labor,  her  social  status,  and,  lastly  and  almost 
of  paramount  importance,  the  temperament  of  the  individual.  Even 
after  a  careful  study  of  each  case  and  a  review  of  all  the  points  bear- 
ing on  it  it  will  in  not  a  few  cases  be  difficult  to  decide  what  course 
will  be  best  for  the  ultimate  welfare  of  the  patient.  The  author 
believes  that,  when  not  contraindicated,  a  period  of  at  least  from 
four  to  six  weeks  should  be  allowed  to  elapse  during  which  the  tempera- 
ture and  the  blood-count  remain  normal,  before  operation  for  intra- 
peritoneal gonorrheal  pelvic  lesions  is  undertaken;  and  that  preliminary 
palliative  treatment  should  be  given  to  all  cases  before  operation. 

'  Aulliorn :  Loc.  cit. 


THE    TREATMENT    OF    PELA'IC    INFLAMMATORY   DISEASE  285 

WTien  possible,  it  is  best  to  operate  about  a  week  or  ten  days  after 
menstruation  has  ceased,  as  at  this  time  less  congestion  is  present  and 
infection  is  probably  somewhat  less  likely  to  occur.  It  has  been  amply 
shown,  bj^  both  bacteriologic  and  clinical  investigation,  that  more  gono- 
cocci  and  other  organisms,  in  cases  of  mixed  infection,  are  present  in 
the  discharge  from  the  genital  tract  at  and  immediately  subsequent  to 
menstruation,  so  that  this  time  would  seem,  at  least  theoreticallj-,  less 
favorable  than  during  the  interval  period.  Hyde,^  however,  believes 
that  work  can  be  done  on  these  cases  as  satisfactorily  during  menstrua- 
tion as  at  any  other  time.  Lovrich-  states  that  during  the  menstrual 
congestion  it  is  much  harder  to  overcome  hemorrhages;  he,  therefore, 
operates  during  menstruation  only  in  cases  where  postponement  is 
impossible. 

CONSERVATIVE   SURGERY   OF   THE   UTERUS  AND   APPENDAGES   IN  CASES 
OF  GONOCOCCAL  PELVIC  PERITONITIS 

The  advantages  to  be  derived  from  conser\'ative  peh'ic  surgery 
are  now  well  recognized.  For  many  years  conservative  surgery  of 
the  pelvic  organs  was  looked  upon  somewhat  doubtfully,  for  a  certain 
proportion  of  the  cases  were  not  subjectively  cured,  and  in  some 
instances  required  secondar}'  operations.  As  has  previously  been 
pointed  out,  preliminary  treatment  greatly  lessens  this  proportion. 
It  is  a  significant  fact  that  those  who  have  most  vigorously  attacked 
this  form  of  conservative  surgery  are  the  operators  who  have  not 
followed  the  after-histories  of  their  cases,  and  who  base  their  asser- 
tions on  general  grounds  that  are  not  borne  out  by  accurate  data. 
Polk,'  in  this  country;  Pozzi,''  in  France;  and  IMartin,*  in  Germany, 
were  among  the  early  advocates  of  conservative  surgery  in  cases  of 
gonorrheal  pelvic  inflammatory  disease.  Conservative  surgery  of  the 
pelvic  organs  may  be  divided  into  operations  on  the  tubes,  ovaries, 
or  uterus. 

CONSERVATIVE  SURGERY  OF  THE  FALLOPIAN  TUBES 

In  the  author's  opinion,  tliis  form  of  surgery  has  a  very  limited 

field.     The  presence  of  pus  in  the  tube  is  an  absolute  indication  for 

its  removal  in  all  cases.     Small  adherent  tubes,  in  which  the  abdominal 

ostia  are  closed,  should  also  be  excised.     The  only  cases  in  which  a 

'  Hydo,  C.  R.:  Amer.  .lour.  Surg.,  April,  lill2,  p.  i:«. 

'Lovrich,  J.:    The  Sixth  Intornational  ( "()ngrcs.s  of  Obstotrici.ins  ami  (!yiicc<)logi.sls, 
Berlin,  ScptPinbcr  9  to  13,  1912;  Surg.,  Gyn.  and  Olxst.,  Decpinljpr,  1912,  p.  7  t:{. 
>  Polk,  .\.  M.:   New  York  Med.  Record,  September  18,  1880. 
*  Pozzi:   Rev.  de  Gyn.,  1S97,  vol.  i,  No.  3. 
'  Martin,  A.:   Volkniaiin's  .Simiiil.  klin.  Vortragc,  1889,  No.  343. 


286  GONORRHEA    IN    WOMEN 

salpingostomy  is  ever  justifiable  is  in  old,  non-active  hydrosalpinges, 
and  in  those  eases  of  tubal  occlusion  or  phimosis  resulting  from  extra- 
tubal  inflammation,  such  as  sometimes  results  from  appendicitis  or 
ectopic  pregnancies.  The  latter  cases  are  obviously  rarely  gonococcal 
in  origin.  The  tubal  contents  being  sterile  and  the  tubal  mucosa 
normal,  except  for  the  results  of  intratubal  pressure,  these  cases  offer 
the  most  favorable  results  from  salpingostomy. 

One  of  the  chief  defects  of  a  simple  salpingostomy  is  that  in  a 
great  number  of  cases  the  intramural  portion  of  the  tube,  as  well  as 
the  abdominal  ostium,  is  occluded.  To  overcome  this,  hysterosal- 
pingostomy  has  been  devised.  The  usual  after-histories  of  all  forms 
of  salpingostomy  show  that  the  newly  formed  ostia  close  and  a 
recurrence  of  symptoms  takes  place,  and  this  despite  the  utmost  care 
displayed  in  performing  the  operation.  The  percentage  of  cases  in 
which  pregnancy  takes  place  after  salpingostomy  has  been  performed 
is  small,  whereas  recurrences  are  frequent.  Turk'  reports  8  cases  in 
which  salpingostomy  was  performed,  2  of  which  subsequently  be- 
came pregnant.  With  one  exception  the  cases,  however,  are  not 
recorded  in  detail,  and  the  condition  of  the  opposite  tube  is  not  stated. 

Gellhorn,'-  Kehrer,-^  ^Nlartin,^  Alackenrodt,^  Skutsch,^  Gersuny,' 
Pozzi,**  and  Stone^  have  all  reported  pregnancies  following  salpingos- 
tomy, while  Polk,'"  Morris,"  Bonifield,'-  Polak'^  (3  cases) ,  and  the  author 
have  had  cases  of  pregnancy  follow  resection  of  a  tube.  Mc Arthur'^ 
states  that  he  has  performed  the  operation  of  salpingostomy  very  fre- 
quently, and  cannot  recall  a  single  successful  physiologic  result.  Small 
or  normal  sized  tubes,  in  which  the  abdominal  ostia  are  open,  may  be 
freed  of  adhesions,  but  better  results  will  usually  be  obtained  by  their 
removal.  The  author  believes  that  unless  there  is  some  indication 
making  maternity  especially  desirable,  a  conservative  operation  on  the 
tubes   should   not    be    performed,   and,  when    possible,   the    patient 

'  Turk,  R.  C:  New  York  Med.  Jour.,  1909,  vol.  Ixxxix,  p.  1193. 

■  Gellhorn,  G.:  Surg.,  Gyn.,  and  Ob.st.,  July,  19U,  p.  10. 

'  Kehrer,  E.:   Monats.  f.  Geb.  u.  Gyn.,  October,  1909. 

'  Martin:  Quoted  by  Kehrer,  E.:  Loc.  cit. 

'Mackenrodt:   Quoted  by  Kehi-er,  E. :  Loc.  cil. 

"Skutsch:  Quoted  by  Prochownik,  L.:  Monats.  f.  Geb.  u.  Gyn.,  1900,  vol.  .xxi.x, 
p.  4.53. 

'Gersuny:   Quoted  by  Prochownik:  Loc.  cil. 

'Pozzi:   Quoted  by  Prochownik:   Loc.  cil. 

'  Stone:  The  Virginia  Med.  Semi-Monthly,  June  7,  1912,  p.  10.5. 

'"  Polk,  W.  M.:  Quoted  by  Kelly,  H.:  Operative  Gyn.,  first  cd.,  1889,  p.  192. 

'•  Morri.«,  L.  C:  Amer.  Jour.  Obst.,  1910,  vol.  Ixii. 

"  Bonifield,  C.  L.:   Amer.  Jour.  Obst.,  1903,  p.  6.5S. 

''  Polak,  J.  O.:  Amer.  Jour.  Obst.,  1910,  vol.  Ixii,  p.  676. 

'<  McArthur,  A.  N.:  Australian  Med.  Jour.,  February  12,  1912,  p.  333. 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  287 

should  be  advised  as  to  the  nature  of  her  condition  and  the  Hkehhood 
of  faihire,  and  should  herself  be  the  one  to  decide  the  nature  of  the 
operation. 

Uffreduzzi'  has  reported  the  results  of  a  series  of  experiments 
performed  for  the  purpose  of  ascertaining  the  ultimate  results  of 
salpingostomy,  Clado's  tubo-ovarian  anastomosis,  and  Gersuny  and 
Doderlein's  utero-ovarian  anastomosis  being  employed.  In  this  series 
19  animals  were  utilized,  and  in  all  the  results  were  disappointing, 
as  far  as  the  possibility  of  subsequent  pregnancy  was  concerned. 

The  general  unsatisfactory  results  obtained  by  conservative  tubal 
surgery  may  be  attributed  to  the  fact  that  the  great  majority  of  tubal 
inflammations  are  of  gonococcal  origin.  One  of  the  chief  characteris- 
tics of  the  gonococcus  is  its  persistence.  After  having  once  established 
itself  in  a  location  suitable  for  its  growth,  it  is  practically  ineradic- 
able unle.ss  the  affected  area  is  so  situated  as  to  be  easil^y  accessi- 
ble to  local  treatment.  It  has  been  shown  that  gonococci  may  lie 
dormant  in  the  tube  for  prolonged  periods,  and  this  persistence  of 
the  organism  accounts  for  many  of  the  failures  in  conservative  surgery. 

The  brighter  side  of  conservative  tubal  surgery  is  observed  when 
we  consider  those  cases  in  which  a  normal  tube  exists  on  one  side  and 
a  diseased  tube  on  the  other.  In.  these  cases  the  normal  tube  should 
be  disturbed  as  little  as  possible.  Excellent  results  have  been  ob- 
tained l)j'  this  treatment,  and  comparatively  few  such  cases  require 
a  secondary  operation.  When  it  is  decided  to  perform  a  salpingec- 
tomy, the  radical  operation,  i.  e.,  the  removal  of  a  wedge-shaped 
portion  of  the  uterine  cornua,  together  with  the  outer  two-thirds  or 
three-fourths  of  the  intramural  part  of  the  tube,  should  be  the  opera- 
tion of  choice.  The  writer  has  recently  seen  two  cases  of  cornual 
abscess  and  one  case  of  intramural  tubal  pregnancy  occurring  in  the 
stump  left  by  a  previous  salpingectomy,  when  the  intramural  ])ortion 
of  the  lube  hail  not  Ix-cn  excised. 

CONSEPVATIVE  OVARIAN  SURGERY 
The  ovary  is  tlic  analogue  of  the  testicle,  and  is  nearly  or  (juite 
as  important  as  that  organ.  For  this  reason  considerable  surgical 
risks  are  justifiable  for  its  preservation.  The  removal  of  diseased 
tubes  merely  renders  the  patient  sterile,  a  condition  that  usually 
exists  before  operation  is  undertaken ;  whereas  a  double  oophorectomy, 
at  least  in  a  certain  i)roportion  of  cases,  converts  a  previously  normal 
woman  into  a  hopeless  neurasthenic.  The  sudden  onset  of  tlie  arti- 
ficial menopause,  with  its  accom])anying  nervous  symptoms,  the  in- 

'  I'lTri'iluzzi   O.:    Aiuiali  di  oslcliiciiic  ninccDloiiinJ'.ll  1,  vol,  ii. 


288  GONORRHEA    IN    WOMEN 

ability  successfully  to  fulfil  the  marital  relations,  together  with  the 
mental  effect  produced  by  the  cessation  of  the  menses,  and  the  knowl- 
edge that  is  more  or  less  suddenly  and  forcilsly  brought  to  the  wo- 
man's mind  that  she  is  prematurely  aged,  and  that  the  possibihties 
of  maternity  have  forever  been  removed — all  these  tend  to  render  the 
patient  miserable.  There  is  no  doubt  that  the  age  at  which  a  double 
oophorectomy  is  performed,  together  with  the  individual  temperament 
of  the  patient,  plays  a  very  decided  part  in  the  after-history  of  these 
cases,  and  that  some  women  bear  the  results  of  the  operation  much 
better  than  do  others.  Too  much  importance,  however,  cannot  be 
placed  on  the  age,  as  Peterson^  has  shown  that  some  of  the  most 
serious  after-effects  follow  the  artificial  production  of  the  menopause 
in  women  between  forty  and  forty-five  years  of  age.  Although  some 
patients  may  be  relatively  little  affected  by  the  operation,  more  than 
half  will  suffer  very  severely,  and  in  a  definite  proportion  the  result 
will  be  little  short  of  appalling. 

One  has  only  to  follow  the  after-histories  of  a  few  cases  to  be 
convinced  of  the  disastrous  effects  of  a  double  oophorectomj^  In  a 
large  series  of  cases  in  which  both  ovaries  were  removed  Giles-  found 
that  the  flushes  and  other  symptoms  of  the  artificial  menopause 
continued  for  from  three  to  four  years  in  most  cases,  and  in  some 
individuals  persisted  for  ten  years.  Severe  mental  depression  occurs 
in  from  10  per  cent,  to  33  per  cent,  of  cases,  whereas  of  157  cases,  2 
became  insane.  Sex  instinct  is  entirely  abolished  in  16  per  cent.,  and 
it  is  only  a  matter  of  time  before  this  is  entirely  lost.  It  has  been 
clahiied  that  the  preservation  of  one  ovary  is  sufficient.  This  state- 
ment is  based  on  the  principle  that  "half  a  loaf  is  better  than  no 
bread."  The  patients  upon  whom  a  unilateral  oophorectomy  is  per- 
formed often  menstruate  scantily  and  undergo  an  early  menopause. 

Dickinson^  states  that  a  review  of  200  cases  in  which  conservation 
of  one  or  both  ovaries  has  been  practised  shows  that  even  when  the 
uterus  has  been  removed,  not  more  than  20  per  cent,  of  the  patients 
suffer  from  the  surgical  menopause.  His  results  were  better  when 
both  ovaries  were  spared  than  when  one  was  removed,  and  that  in 
the  latter  class  of  cases  the  menopause  was  likely  to  occur  somewhat 
earlier  than  in  the  normal  woman.  Giles,''  after  a  careful  review  of 
1000  abdominal  sections,  of  which  50  were  unilateral  salpingo-oophor- 
ectomies  for  pelvic  inflammatory  disease,  concludes  that  the  removal 

'  Peterson,  R.:    Amer.  Jour.  Obst.,  May,  1908. 

'  Giles,  A.  E.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  March  and  April,  1910. 

'  Dickinson,  R.  L.:  Trans.  Amer.  Gyn.  Soc,  vol.  xxxvi,  p.  .324. 

'  Giles,  A.  E.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  March  and  April,  1910. 


THE  TREATMENT  OF  PELVIC  IXFLAMMATORY  DISEASE      289 

of  one  ovary  causes  irregularities,  diniiiiution,  or  cessation  of  the  men- 
strual flow  in  a  definite  proportion  of  cases  (16  per  cent,  of  his),  and 
that  in  a  somewhat  smaller  proportion  (12  per  cent.)  the  sexual  desire 
is  lessened  or  abolished.  In  133  of  our  own  cases  at  the  University 
Hospital  in  which  one  ovary  had  been  removed,  menstruation  was 
diminished  or  irregular  in  50. 

Carmichael,'  Valtorta,-  and  Mcllroy''  found  that  in  animal  ex- 
perimentation, when  one  ovary  was  excised,  there  was  a  permanent 
compensatory  hypertrophj^  of  the  other,  and  this  doubtless  takes 
place  to  a  certain  extent  in  women  and  may  account  for  some  of  the 
irregular  bleedings  that  occasionally  follow  unilateral  oophorectom}\ 
Mcllroy  also  states  that  the  uterine  function  and  nutrition  seem  to 
depend  upon  the  ovarian  secretion,  as  atrophy  occurred  after  bilateral 
oophorectomy.  The  myometrium  was  the  first  to  show  atrophj-; 
the  glands  of  the  mucosa  disappeared  graduallj%  and  the  surface 
epithelium  retained  its  normal  condition  the  longest.  The  mam- 
mary glands  and  the  external  genitalia  were  likewise  invariably  atro- 
phied. Atrophic  changes  in  the  uterus  following  the  removal  of  the 
ovaries  prior  to  the  establishment  of  the  normal  menopause  have  been 
observed  by  Knauer,'*  Gigorieff,^  Ribbert,^  HalbanJ  Rubinstein,^  and 
many  others. 

A  further  comi)arison  between  the  tube  and  ovary  shows  that  the 
essential  structure  of  the  tube,  i.  e.,  the  mucosa,  is  chiefly  involved, 
whereas  in  the  ovary,  at  least  in  gonococcal  infections,  the  important 
constituents  are  destroyed  only  in  the  last  stages  of  the  disease.  A 
peri-oophoritis  is  the  most  frequent  accompaniment  of  a  pyosalpinx, 
and  usually  only  in  the  advanced  cases  is  an  actual  oophoritis  present. 
For  this  reason,  when  the  primary  source  of  the  infection  is  removed, 
the  ovary  is  prone  to  undergo  resolution.  In  examining  the  his- 
tologic diagnoses  of  490  ovaries  removed  consecutively  for  pelvic 
inflammatory  disease  at  the  University  Hospital,  the  author  found 
260  ca.ses  of  peri-oophoritis,  thus  showing  the  relative  frequency'  of 
this  condition. 

In  this  connection  it  must  be  reinoml)ored  that  this  is  a  conserva- 

'  Carmichiiol,  K.  S.:   Kdinhuriih  Mc.l.  Joui'.,  .\I;irch,  V.)Od,  p.  242. 

•  Valtorta,  F.:  Ann.  di  ostot.  u  gin.,  .July,  liUl. 

*  Mcllroy:  Jour.  Olwt.  and  Gyn.  of  Brit.  Enip.,  July,  1912. 

«  Knaucr:  Zent.  f.  (lyn.,  1890,  vol.  xx,  No.  2;  also  ibi'l.,  189S,  vol.  xxii,  p.  21)1;  also 
Wien.  klin.  Woch.,  1.S99,  vol.  xii;  also  .Vrch.  f.  (!yn.,  1900,  vol.  ix;  also  Stevens'  Jour,  of 
Obst.  and  Gyn.,  January,  1904,  vol.  v. 

'  GigoricfT:  Zent.  f.  Gyn.,  1897,  vol.  xxi. 

•Ribbert:  Arch.  f.  Enlwiok.-Mechanik,  1898,  vol.  vii. 

'  Halban:  Monats.  f.  Geb.  u.  Gyn.,  vol.  xii,  No.  4,  p.  49ii. 

•Kubinslciii,  II.:   St.  IVtershurK.  mod.  Woch.,  1899,  No.  31,  p.  281. 
19 


290  GONORRHEA    IN    WOMEN 

tive  clinic,  and  while  probably  all,  or  nearly  all,  the  ovaries  the  seat 
of  advanced  inflammatory  lesions  have  been  removed,  many  organs 
that  would  have  been  classified  under  the  head  of  peri-oophoritis  have 
been  spared,  so  that  the  relative  proportion  of  peri-oophoritis  and 
oophoritis  is  even  more  marked  than  would  appear  from  the  foregoing 
figures.  It  is  impossible  to  formulate  any  hard  and  fast  rules  govern- 
ing the  removal  or  conservation  of  an  ovary,  as  this  is  dependent  upon 
so  many  factors.  Polak'  emphasizes  the  fact  that  an  enlarged  ovary 
is  not  necessarily  a  diseased  one. 

SALPINGECTOMY.     OVAPIAN   CONSERVATION  AND   SUSPENSION  OF  THE 

UTERUS 

As  has  been  repeatedly  stated  elsewhere,  successful  ovarian  con- 
servation after  salpingectomy  is  dependent  chiefly  upon  three  factors: 
(1)  The  surgical  judgment  of  the  operator — it  is  obviously  unwise 
to  conserve  an  ovary  in  which  the  disease  is  of  such  a  character  as 
to  make  it  certain  that  it  will  continue  to  progress  after  removal  of 
the  tube.  (2)  Non-interference  with  the  blood-supply  of  the  ovary. 
(3)  Maintaining  the  ovary  in  a  favorable  position,  preferably  in  its 
normal  situation. 

Condition  of  the  Ovary. — The  indications  for  or  against  oophor- 
ectomy have  previously  been  stated,  and  attention  has  been  called  to 
the  necessity  of  studying  the  pathology  in  situ,  the  variety  of  the 
infection,  the  points  bearing  on  the  individual  case,  such  as  the  age 
of  the  patient,  her  nervous  temperament,  the  desire  for  maternity, 
the  condition  of  the  opposite  ovary,  the  correlation  of  the  circumstances 
attending  each  individual  case,  and  the  study  of  the  after-histories  of 
such  cases  previously  operated  upon.  Even  a  small  series  of  cases 
carefully  studied  is  of  much  more  value  in  perfecting  the  surgical 
judgment  than  is  a  large  series  superficially  reviewed. 

The  importance  of  maintaining  an  adequate  blood-supply  to  the 
ovary  can  hardly  be  overestimated.  Lack  of  care  in  this  respect  is 
responsible  for  the  majority  of  failures  following  this  operation. 
Clinical  and  experimental  investigation  has  repeatedly  demonstrated 
that  if  the  blood-supply  is  seriously  impaired,  enlargement,  due  to 
cystic  degeneration  and  edema,  and  the  production  of  symptoms 
often  so  severe  as  to  require  operation,  will  result.  In  the  more 
favorable  cases  the  cystic  change  is  followed  by  atrophy.  In  con- 
sidering the  operation  of  salpingectomy,  it  is  important  to  remember 
the  results  that  follow  ligation  of  a  blood-vessel.  When  a  vessel  ^ 
tied  ofT,  its  lumen,  for  a  varying  distance,  becomes  occluded  by 

'  Polak,  J.  0.:  Amer.  Jour.  Med.  Assoc,  December  14,  1912,  p.  2138. 


THE  TREATMENT  OF  PELVIC  INFLAMMATORY  DISEASE 


291 


tkrombus,  which  in  many  cases  extends  to  the  main  trunk  from  which 
the  vessel  originated,  with  the  result  that  the  thrombosed  portion 
of  the  vessel  becomes  converted  into  a  fibrous  cord.  Thus  it  must 
be  borne  in  mind  that  when  ligating  an  artery  in  the  upper  part  of  the 
broad  hgament,  the  area  supplied  by  the  vessel,  for  some  distance  to- 
ward the  cardiac  side  of  the  ligature,  is  obhterated.     It  is  true  that 


Fig,  29. — Diagram  of  the  Blood-supply  op  the  Fallopian  Tube. 
This  drawing  is  the  result  of  a  large  series  of  injections  made  for  the  purpose  of  ascertaining  the  tubal  blood- 
supply,  and  although  the  small  vessels  varj'  somewhat  in  different  specimens,  the  usual  picture  is  that  here 
represented.  A  group  of  blood-vessels  supplies  the  ampulla  of  the  tube.  These  vessels  are  almost  constantly 
present.  Another  vessel  supplies  the  isthmus.  In  about  15  per  cent,  of  cases  this  vessel  branches  slightly  above 
the  ovary,  forming  two  trunks  before  reaching  the  tube.  At  the  point  of  the  utero-ovarian  anastomosis,  just 
beneath  the  cornu  of  the  uterus,  one  or  two  vessels  are  given  off,  which  penetrate  the  myometrium  immediately 
beneath  the  tube.  It  is  of  the  utmost  importance,  when  jwrforming  a  salpingectomy  and  conservation  of  the 
ovary,  that  these  vessels  be  ligated  and  not  the  underlying  utero-ovarian  anastomosis.  If,  inadvertently,  the 
utero-ovarian  anastomosis  is  included  in  the  ligature,  disturbance  of  the  ovarian  circulation,  with  subsequent 
cystic  change  of  the  ovary,  is  almost  sure  to  occur. 


the  collateral  circulation  more  or  less  compensates  for  this  deficit. 
But  when  the  blood-supply  of  the  ovary  and  upper  portion  of  the 
broad  ligament  is  carefully  studied,  it  can  easily  be  seen  how  ligation 
en  masae,  such  as  is  often  practised  during  the  permforance  of  sal- 
pingectomy, is  certain  greatlj'  to  disturb  the  circulation  of  the  ovary. 
If  the  chief  vessels  comprising  the  utero-ovarian  anastomosis  are 
ligated,  as  they  may  easily  be  unless  the  ligatures  are  introduced  with 


292  GONORRHEA    IN    WOMEN 

this  point  in  mind,  subsequent  degeneration  of  the  ovary  is  sure  to 
occur.  The  utero-ovarian  anastomosis  is  especially  likely  to  be  ligated 
at  the  uterine  cornua,  where  the  large  vessels  approach  the  tube 
somewhat  closely. 

Clark^  has  shown  that  the  primordial  follicles  that  normally  de- 
velop in  the  substance  of  the  ovary  reach  the  surface  as  a  result  of 
two  factors,  namely,  increase  in  size  and  the  fact  that  they  are  pushed 
to  the  periphery  by  the  constant  pulsation  of  the  ovarian  arteries 
behind  them.  It  would  seem  safe  to  assume  that  when  the  ovarian 
circulation  is  impaired,  the  ovarian  arteries  pulsate  with  less  force, 
so  that  although  the  maturing  follicle  might  reach  the  periphery  of 
the  ovary,  the  arteries  would  not  possess  sufficient  pulsating  force  to 
produce  a  necrosis  of  the  tunica  albuginea,  lying  between  the  follicle 
and  the  surface,  and  which,  in  the  normal  ovary,  occurs  just  before 
the  rupture  of  the  follicle.  Under  such  circumstances  the  follicle, 
coming  in  contact  with  the  dense  and  perhaps  thickened  tunica  al- 
buginea, would  fail  to  rupture  and  result  in  a  retention  cyst.  This 
the  author  believes  to  be  one  of  the  chief  reasons  why  cystic  degenera- 
tion follows  impairment  of  the  blood-supply  in  this  locality.  The  peri- 
oophoritis which  results  in  thickening  of  the  capsule  of  the  ovary  that 
is  often  present,  and  the  impairment  of  the  return  venous  circulation, 
as  suggested  by  Brown,^  which  causes  edema,  are  also  contributing 
factors. 

No  matter  how  carefully  the  ovarian  blood-supply  is  conserved 
at  operation,  if  the  ovary  is  allowed  to  prolapse,  dyspareunia  is  sure 
to  occur,  and  edema  and  cystic  degeneration,  due  to  deranged  blood- 
supply,  are  likely  to  follow.  If,  on  the  other  hand,  the  mesosalpinx 
is  put  on  the  stretch  by  improper  ovarian  suspension,  the  lumen  of 
the  ovarian  vessels  is  decreased  as  a  result  of  tension,  and  a  similar 
result  takes  place.  In  other  words,  the  correct  introduction  of  liga- 
tures and  suspension  of  the  ovary  are  both  essential  for  the  proper 
maintenance  of  the  blood-supply  and  hence  to  successful  ovarian  con- 
servation. If  the  ovarian  circulation  cannot  be  properly  conserved, 
oophorectomy  should  be  performed. 

Two  other  important  factors  contribute  to  the  ultimate  success  of 
this  type  of  operation :  these  are  the  suspension  of  the  uterus  and  care- 
ful peritonealization.  In  cases  of  pelvic  peritonitis  the  great  majority 
of  uteri  are  more  or  less  retrodisplaced.  No  matter  how  carefully  the 
salpingectomy  and  ovarian  suspension  have  been  performed,  if  the 
uterus  is  left  in  a  posterior  position,  subsequent  trouble  is  likely  to 

'  Clark,  J.  G.:  Contributions  to  the  Science  of  Medicine,  1900. 

'  Brown,  L.  R.:  Jour.  Amer.  Med.  Assoc,  December  14,  1912,  p.  2140. 


Fig.  31. — Bilateral  Salpingectomy,  Ovarian  Conservation,  and  Suspension  of  the  Ovary  and  Uterus. 
First  step;  The  blood-vessels  supplying  the  ampulla  and  isthmus  of  the  Fallopian  tube  have  been  ligated, 
and  the  ends  of  the  former  ligature  left  long  for  a  tractor.  The  tube  has  been  excised  as  far  as  its  uterine  attach- 
ment, and  the  ligature  to  control  the  vessels  supplying  the  intramural  portion  of  the  tube  has  been  inserted, 
but  not  tied.  A  broad  cuff  of  mesosalpinx  has  been  conserved  above  the  ovary.  (The  suture  to  control  the 
subtubal  vessels  should  be  passed  somewhat  more  deeply  into  the  uterus  than  shown  in  the  above.) 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  293 

occur.  These  details  are  repeated  here  because  the  author  beUeves 
them  to  be  of  great  importance,  and  hence  will  explain  the  necessity 
for  the  steps  in  the  following  operation  in  contradistinction  to  the  older 
methods  of  salpingectomy. 

Operation. — A  median  incision  of  sufficient  length  to  allow  a  free 
exposure  should  be  made.  With  the  patient  completely  anesthetized 
and  in  the  Trendelenburg  position,  the  intestines  are  packed  back. 
Thorough  walling  off  of  the  upper  peritoneal  cavity  is  an  important 
step  in  all  abdominal  operations  for  pelvic  inflammatory  disease. 
Adhesions  are  then  separated,  especial  care  being  taken  to  free  the  tube 
throughout  its  length  from  adhesions  that  may  bind  it  to  the  ovary  or 
broad  ligament.  This  is  of  importance  so  that  as  broad  a  portion  of 
the  mesosalpinx  as  possible  may  be  present  before  excision  of  the  tube  is 
begun.  A  fine  catgut  suture  is  then  passed  through  the  upper  portion 
of  the  mesosalpinx,  about  0.5  or  0.75  cm.  below  the  tube,  and  about 
1.5  or  2  cm.  from  the  outer  edge  of  the  infundibulopelvic  ligament. 
This  is  tied,  and  the  ends  are  left  long  for  use  as  a  tractor.  This 
ligature  controls  the  blood-vessels  supplying  the  distal  centimeter  or 
two  of  the  tube.  The  outer  end  of  the  tube  is  then  grasped  with  a 
hemostat,  and  the  tube  cut  from  the  mesosalpinx  to  a  point  about  0.5 
cm.  from  its  uterine  extremity,  especial  care  being  taken  to  incise  the 
mesosalpinx  through  its  extreme  upper  border,  so  as  to  leave  the  blood- 
supply  of  the  ovarj'  unimpaired,  and  a  broad  cuff  of  mesosalpinx  above 
the  ovary  for  future  use  in  the  ovarian  suspension.  After  separating 
the  tube  from  the  mesosalpinx  one  or  sometimes  two  blood-vessels 
are  commonly  seen  spurting  in  the  regions  that  lie  beneath  the  inner 
portion  of  the  ampulla  of  the  tube  and  the  isthmus.  In  his  injection 
work  the  author  has  found  one  vessel  quite  constantly  in  this  locality. 
This  bleeding  is  now  secured  with  a  fine  catgut  ligature,  care  being  taken 
to  pass  the  ligature  through  the  upper  borders  of  the  cut  edge  of  the 
mesosalpinx,  and  to  tie  it  in  such  manner  that  the  latter  is  not  puckered. 
By  puckering  the  free  edge  of  the  mesosalpinx  the  latter  is  shortened, 
and  the  underlying  blood-vessels  are  also  puckered  to  a  greater  or 
lesser  extent  and  the  circulation  thereby  impaired.  If  the  sutures  are 
pa.ssed  through  the  mesosalpinx  at  some  distance  from  its  cut  edge, 
more  blood-vessels  than  are  necessary  are  ligated,  with  a  .similar 
result.  Only  sufficient  mesosalpinx  should  be  included  in  this  suture 
to  secure  safe  anchorage  for  the  ligature.  By  separating  the  tube  from 
the  inesosali)inx  as  just  descriln'd,  before  ligating,  the  individual  ves- 
sel or  vessels  maj'  be  more  easily  picked  up,  fewer  sutures  are  re(|uire(l, 
and  puckering  is  less  likely  to  occur.  As  an  extra  precaution  against 
infection  the  tube  may  at  this  jxiint  \)v  \\\-a\)\)M  in  a  piece  of  sterile 


294 


GONORRHEA    IN    WOMEN 


gauze.  A  suture  should  next  be  passed  through  the  lateral  uterine 
wall,  immediately  beneath  the  intramural  portion  of  the  tube.  Especial 
care  should  be  observed  to  see  that  this  suture  embraces  only  the  ex- 
treme upper  and  inner  edge  of  the  mesosalpinx.  If  the  suture  is  passed 
deeply  into  the  broad  ligament,  the  utero-ovarian  anastomosis  may  be 
ligated.  The  author's  injection  work  has  shown  that  there  is  always 
one  and  sometimes  two  branches  given  off  from  the  utero-ovarian 
anastomosis  at  this  point,  and  that  these  enter  the  uterus  immediately 
beneath  the  tube — the  subtubal  vessels;  it  is  to  control  these  vessels 
that  this  ligature  is  employed.  The  intramural  portion  of  the  tube  is 
excised  with  the  ordinary  wedged-shaped  incision,  and  the  uterine  wound 
closed  with  two  or  three  interrupted  fine  catgut  sutures.  Richardson's' 
single  or  double  figure-of-8  suture  serves  admirably  for  this  purpose. 
The  round  ligament  is  now  picked  up  at  a  point 
about  2  or  .3  cm.  from  the  uterus,  and  drawn  up 
and  plicated,  by  means  of  two  or  three  fine  Pagen- 
stecher  sutures,  over  the  uterine  wound.  If  it  is 
deemed  advisable,  a  greater  portion  of  the  round 
ligament  may  be  utilized — enough  to  bring  the 
uterus  forward  in  good  position.  This  procedure 
shortens  the  round  ligament,  elevates  it  in  the 
pelvis,  suspends  the  uterus,  and  covers  in  the 
uterine  salpingectomy  wound  and  the  inner  two- 
thirds  or  three-fourths  of  the  raw  edge  of  the 
mesosalpinx.  The  extreme  upper  edge  of  the 
cuff  of  mesosalpinx  above  the  ovary  is  then 
sutured  to  the  round  ligament  by  means  of  two  or  three  catgut  sutures, 
the  same  care  being  observed  in  passing  these  sutures .  through  the 
mesosalpinx  as  was  taken  in  ligating  the  blood-vessels.  Except  that 
the  ovary  is  drawn  forward  1  or  2  cm.,  its  normal  position  is  retained,  the 
organ  hanging  naturally  on  the  posterior  surface  of  the  broad  ligament. 
Even  an  enlarged  and  heavy  ovary  can  be  well  suspended  in  this  man- 
ner. If,  however,  the  ovary  to  be  conserved  is  the  seat  of  one  or  two 
large  retention  cysts,  it  is  a  better  plan  to  puncture  these  and  thus  re- 
duce the  weight  of  the  organ.  The  operation  may  cease  at  this  point, 
as  practically  all  the  requirements  have  been  fulfilled.  If  the  peri- 
toneum is  not  too  adherent,  the  author  prefers  to  utilize  this  structure 
also  for  the  uterine  suspension.  Coffey-  has  shown  its  great  value 
in  this  connection.  The  peritoneum  on  the  anterior  surface  of  the 
broad  ligament,  at  a  point  about  3  cm.  below  and  1  cm.  outside  of  the 

'  Richardson,  Edward  H.:  Jour.  Amer.  Med.  Assoc,  May  7,  1910,  vol.  liv,  p.  500. 
=  Coffey,  Robert  C:  Surg.,  Gyn.,  and  Obst.,  October,  1910. 


Fig.  32.— Rich-\rdson's  Sin- 
gle (a)  AND  Double  (b) 
FionRE-OF^S  Suture 
(Richardson,  E.  H.:  .Jour. 
Amer.  Med.  Assocs  May 
7,  1910). 


1 


I'l';.  ;i3. — BiLATKHAi.  SvLi-iNGECTOMv,  Ovarian  Conservation,  AND  SusPExsinN  -t  im  >  ,  -  :  >.  .  i  ii  ,  .  - 
Second  atep:  Hemostasis  has  been  secured,  as  shown  in  the  previous  illustration,  and  the  wounds  left  from 
the  excision  of  the  intramural  portion  of  the  tubes  have  been  closed  by  two  or  three  interrupted  sutures  of  fine 
catgut  or  by  Richardson's  figure-of-8  stitch.  The  round  ligaments  have  been  plicated  over  the  uterine  wound 
by  two  or  three  Pagenstecher  threads,  sufficient  of  the  ligaments  being  utihzed  to  effect  a  suspension  of 
the  uterus.  On  the  patient's  right  side  of  the  ovaiian  suspension  sutures  are  in  place,  but  not  tied,  while  on 
the  left  side  the  ovary  has  been  suspended.  If  the  peritoneum  of  tho  anterior  layer  of  the  broad  ligament  is 
unusually  adhert-nf.  the  operation  may  cease  at  this  point. 


Fio.  ."M. — DtLATBnAL  SALPiNnKtrroMV,  Ovarian  Conservation,  and  Suspension  of  the  Ovary  and  TTEKrH. 
Third  Htep:   It  in  of  advantage,  when  possible,  to  utilize  the  peritoneum  of  the  anterior  layer  of  the  broad 
I  Muspension  medium.     For  thih"  purpose  a  point  somewhat  below  and  ulightly  outside  of  the  uterine 

iired  to  the  uterus 
illimtnition.  The 
id  ligament  irt  not 


lianment  1) 

insertion  of  the  roun<l  liganient  is  selected,  and  the  peritoneum  from  here  lifted  up  am 
over  the  plieated  portion  of  the  round  ligamenl  by  a  fine  eatgul  suture,  as  shown  in 
Cuihing  Htiteh  is  a  Roml  one  for  this  purpose.     If  the  stump  at  the  outer  end  of  the 


mI  by  this  procedure,  entire  peritonealization  may  be  accompliMhe<l  by  a  fine  catgut  sutur 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  295 

origin  of  the  round  ligament,  is  lifted  up  and  tacked  over  the  pHcated 
round  Hgament  on  the  uterine  cornua,  so  as  to  envelop  the  latter. 
This  entirely  covers  all  raw  areas  and  adds  materially  to  the  strength 
of  the  uterine  suspension.  If  the  appendages  of  the  opposite  side  are 
normal,  the  ordinary  Coffey  uterine  suspension  operation  may  be  per- 
formed on  that  side.  In  cases  in  which  it  is  necessary  to  perform  a 
salpingo-oophorectomy  the  same  method  of  plication  of  the  round  liga- 
ment and  peritonealization  may  be  employed. 

The  salpingectomy,  as  previouslj'  described,  although  somewhat 
more  tedious  than  the  ordinary  operation,  has  been  productive  of  so 
much  better  results,  so  far  as  the  ultimate  ovarian  conservation  is 
concerned,  that  the  author  has  practically  al^andoned  all  other  methods 
in  its  favor.  In  one  case  in  which  an  opportunity  arose  to  examine  the 
suspended  ovarj'  nearly  one  year  after  the  suspension,  the  organ  was 
found  to  be  in  excellent  condition.  In  three  other  cases  in  which 
unilateral  salpingectomy  has  been  performed  pregnancy  has  fol- 
lowed and  the  subsequent  labors  have  been  normal,  and  the  uteri 
have  retained  their  normal  positions.  An  endeavor  has  been  made 
to  keep  track  of  all  cases,  and  a  large  number  have  been  examined 
binianually  from  time  to  time.  In  all  those  operated  upon  by  this 
method  good  results  have  been  obtained  so  far  as  ovarian  conservation 
is  concerned,  and  in  no  case,  as  far  as  has  been  learned,  have  degenera- 
tive changes  taken  place  in  the  retained  ovary,  nor  have  any  of  these 
ovaries  given  rise  to  subjective  symptoms.  The  proportion  of  cases 
in  which  normal  menstruation  has  been  retained  after  a  salpingo- 
oophorcctom}'  on  one  side,  and  a  suspension  of  the  ovary  by  the  fore- 
going means  on  the  ojiposite  side,  is  distinctly  l)etter  tlian  when  other 
methods  have  been  employed. 

Before  adopting  the  method  just  described,  a  number  of  operations 
for  ovarian  suspension  have  been  tested  in  the  Gynecologic  Depart- 
ment of  the  University  Hospital.  At  first  the  ovary  was  let  alone 
after  excision  of  the  tube,  and  then  an  endeavor  was  made  to  suspend 
the  ovary  fioin  the  round  ligament  without  plicating  the  latter. 
Neither  of  these  operations  was  entirely  satisfactory,  and  for  a  time  the 
ovary  was  suspended  from  the  cornua  of  the  uterus.  If  mass  sutures 
are  employeil  in  tying  off  the  mesosalpinx,  this  structure  l)ecomes  nnich 
puckered,  and  a  false  sense  of  ease  is  (>ncf)untereil  in  bringing  the  ovary 
to  the  uterine  cornua.  Such  a  procedure  interferes  materially  with  tiie 
ovarian  circulation,  and  in  a  large  jiroportion  of  cases  degeneration  of 
tlic  ()\ary  results. 

Partial  Oophorectomy.  In  sonic  cases  resection  of  an  o\'ary  offers 
fiiv()ral)Ic  results.     The  presence  of  pus  in  the  ovary  is  usuall,\'  an  iiidi- 


296  GONORRHEA    IN    WOMEN 

cation  for  its  removal.  Esch^  regards  the  pus  contained  in  ovarian 
abscesses  as  peculiarly  virulent.  Many  such  cases  are  undoubtedly 
of  puerperal  origin,  the  pyogenic  microorganisms  having  traveled  di- 
rectly through  the  broad  ligament  to  the  ovary.  Notwithstanding 
this,  in  carefully  selected  cases  resection  may  be  performed  with  fairly 
good  results.  If  it  is  found  necessary  to  remove  the  opposite  ovary, 
or  if  the  abscess  is  a  small  one  and  is  so  situated  that  it  may  easily 
be  excised,  and  even  if  only  a  small  amount  of  ovarian  tissue  can  be 
left  behind,  the  sudden  onset  of  the  menopause  is  generally  averted. 

Stokes-  has  had  three  cases  of  pregnancy  following  complete 
removal  of  one  ovary  and  at  the  same  time  the  major  portion  of  the 
opposite  one,  showing  definitely  that  in  suitable  cases,  and  when  the 
operation  is  properly  performed,  these  ovaries  functionate  in  a  normal 
manner.  Humiston^  reports  112  cases  with  no  mortality.  The  after- 
histories  of  70  of  these  cases  have  been  followed :  19  of  the  number  have 
given  birth  to  21  children,  and  3  have  returned  for  a  second  operation. 
None  of  the  cases  included  in  this  list  have  been  operated  upon  less 
than  three  years  ago.  The  condition  of  the  opposite  ovary  is  not 
stated. 

Watkins^  states  that  he  resects  small  abscesses  in  the  ovaries  in 
young  women,  preferring  to  run  the  risk  of  secondary  trouble  to  pro- 
ducing an  early  menopause.     As  yet  he  has  had  no  unfavorable  results. 

In  general  it  may  be  stated  that  resection  of  an  ovary  possesses  a 
limited  field  of  usefulness  in  gonorrheal  conditions,  the  proportion  of 
those  cases  that' require  a  secondary  operation  being  much  higher  than 
where  an  entire  ovary  is  conserved.  This  is  due  to  two  factors:  in 
the  first  place,  resected  ovaries  are  always  diseased  organs,  and  in 
the  second  place,  apart  from  the  mutilation  necessary,  the  circulation 
is  often  interfered  with  by  the  ovarian  sutures.  These  are  necessarily 
passed  deeply  into  the  substance  of  the  ovary,  and  as  this  organ  is  sup- 
plied by  a  central  circulation,  the  latter  is  always  more  or  less  dis- 
turbed. Furthermore,  the  follicle-bearing  portion  of  the  ovary  is 
usually  the  part  diseased,  and  therefore  the  most  important  portion 
of  the  ovary  is  likely  to  be  removed  by  resection.  Polak,^  in  his  pains- 
taking study  of  the  after-histories  of  these  cases,  remarks  that  all 
resected  ovaries  become  much  enlarged  after  the  operation.  In  the 
favorable  cases  this  enlargement  begins  to  subside  in  about  four  weeks. 

'  Esch:  Zeitschr.  f.  Geb.  u.  Gyn.,  1907,  vol.  lix,  No.  1. 

-  Stokes,  J.  E.:   Old  Dominion  Jour.  Med.  and  Surg.,  Richmond,  1911,  vol.  xii,  p.  2.iri. 

^  Humiston,  W.  H.:  Amer.  Jour.  Obst.,  January,  1913,  p.  120. 

*  Watkins,  T.  J.:  Jour.  Amer.  Med.  Assoc,  December  14,  1912,  p.  2140. 

'  Polak,  J.  O. :  Jour.  Amer.  Med.  Assoc,  October  23,  1909,  p.  1382. 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  297 

Turretta^  has  studied  the  after-results  in  a  large  series  of  ovarian  re- 
sections, and  speaks  favorably  of  the  operation  in  selected  cases; 
he  believes  that  the  reparative  power  of  the  ovary  is  very  great. 
Zacharias-  has  traced  the  after-histories  of  three  cases,  in  each  of  which 
one  ovary  was  removed  and  the  other  resected.  In  none  of  these 
patients  did  any  untoward  symptoms  arise,  and  all  were  menstruating 
regularly  several  years  after  the  operation.  Pugnat'  believes  firmly 
in  the  regenerative  power  of  the  ovary,  and  declares  that  new  germinal 
epithelium  is  produced,  together  with  the  formation  of  new  primordial 
and  Graafian  follicles.  This  latter  statement,  while  interesting, 
must  be  confirmed  bj'  further  observation  before  it  can  be  accepted. 
Di  Christina^  believes  that  the  cut  surfaces  of  a  resected  ovary  heal 
by  connective-tissue  production,  and  that  the  cicatrix  is  generally 
pushed  to  the  surface.  The  author  had  the  opportunity  of  examining 
histologically  two  ovaries  upon  which  resection  had  been  performed. 
Serial  sections  were  made  of  these  organs,  and  no  confirmatorj'  evi- 
dence was  obtained  that  new  ovarian  tissue  was  produced  to  take  the 
place  of  the  resected  portion.  Both  specimens  were  of  nearly  normal 
size.  In  one  the  scar  could  be  distinguished  macroscopically,  whereas 
in  the  other  it  could  be  detected  only  microscopically  as  a  thin  line 
of  avascular  connective  tissue  on  the  surface.  That  compensatory 
hj'pertrophy — a  verj^  different  process  from  regeneration — does  take 
place  seems  to  be  certain.  This  belief  is  borne  out  b\'  the  study  of 
clinical  material  and  bj'  the  work  of  Carmichael  and  Marshall,^  which 
has  been  discussed  elsewhere. 

The  most  favorable  cases  for  resection  are  those  in  which  a  single 
retention  cyst  is  present,  and  this  is  especially  true  when  the  cyst  tends 
to  become  pedunculated.  These  single  retention  cysts  should  not  be 
confused  with  cystic  degeneration  of  the  ovaries.  The  latter  condi- 
tion offers  very  poor  results  from  any  form  of  conservative  surgery. 
Boldt,^  in  performing  oophorocystectomy,  endeavors  to  save  a  portion 
of  the  ovary,  and  in  45  cases  had  only  one  bad  result.  The  necessity 
for  leaving  the  ovary  with  an  unimpaired  blood-supply  cannot  be  over- 
estimated, and  if  this  is  found  to  be  impossible,  ooi)horectomy  should 
be  performotl. 

It  has  been  stated  that  ovaries  that  are  allowed  to  remain  after 
removal  of  the  uterus  or  of  the  corresponding  tube  give  rise  to  subse- 

'  Tiiru'tta,  S.:   II  Policlinico,  January  3,  1909. 
'  Zaohuriii-s,  P.:  Zeit.  f.  Gyn.,  Leipzig,  January  25,  1908. 
'  I'unnat:  Quoted  Ijy  Di  Christina:  Monats.  f.  Geb.  u.  Gyn.,  vol.  xxii,  No.  5. 
•'  Di  Christina:   Monat.s.  f.  C!ol).  u.  Gyn.,  vol.  xxii,  No.  ii. 

'  Carmichael,  E.  S.,  and  Marshall,  F.  A.  V.:  Brit.  Med.  Jour.,  1907,  vol.  ii,  p.  I.'j72. 
'  Ho!(lt,  H.  J.:  Trans.  Amer.  Gyn.  Soc.,  Philadelphia,  1909,  vol.  xxxiv,  p.  .327. 


298  GONORRHEA    IN    WOMEN 

quent  trouble,  often  undergoing  polycystic  degeneration  and  becoming 
enlarged  and  tender,  and  sometimes  prolapsing  into  Douglas'  culdesac ; 
or  if  this  does  not  occur,  that  they  become  adherent  and  painful. 
Unfortunately,  there  is  no  doubt  that  this  is  sometimes  the  case. 
The  author  is,  however,  of  the  opinion  that  in  these  cases  the  fault  lies 
not  so  much  in  the  ovary,  as  in  the  method  of  performing  the  sal- 
pingectomy. 

The  important  factors  to  be  considered  in  conservative  ovarian 
surgery  are  the  maintenance  of  a  proper  blood-supply  and  the  securing 
of  the  ovary  in  good  position,  preferably  in  its  normal  location  in  the 
fossa  obturatoria  (Waldeyer).  If  these  two  points  are  observed, 
cystic  degeneration  of  the  ovary,  dyspareunia,  and  other  distressing 
symptoms  can  be  averted.  Furthermore,  this  opinion  is  strengthened 
by  the  review  of  the  after-histories  of  engrafted  ovaries,  which  almost 
invariably  become  cystic.  Souve,^  in  his  exhaustive  study  of  ovarian 
transplantation,  finds  that  cystic  degeneration  almost  uniformly 
supervenes.  This,  he  believes,  is  due  to  an  imperfect  blood-supply. 
A  similar  conclusion  is  reached  by  Kawasoye,^  Mcllroy,^  and  others. 
Special  attention  should  be  directed  to  covering  all  raw  areas,  so  that 
adjacent  organs  may  not  become  adherent,  and,  by  the  formation  of 
post-operative  adhesions,  cause  as  much  discomfort  as  the  original 
condition.  All  rough  handling  and  trauma  of  the  ovary  during  the 
operation  should  be  avoided.  In  those  cases  in  which  a  resection  has 
been  performed,  especial  care  should  be  taken  accurately  to  coaptate 
the  cut  surfaces' of  the  ovary,  but  not  to  constrict  the  tissue  in  doing  so. 
Fine  catgut  sutures  should  be  passed  in  such  a  way  that  no  dead  space 
will  remain.  Absolute  asepsis  and  hemostasis  should  be  secured. 
Martin''  very  properly  strongly  emphasizes  the  necessity  of  checking 
all  bleeding  points  in  cases  of  pelvic  inflammatory  disease.  No  better 
culture-media  exist  than  blood-clots.  A  fine  needle  and  fine  catgut 
are  requisites  to  successful  conservative  ovarian  surgery. 

In  conserving  ovaries,  as  in  all  other  forms  of  surgery,  the  ability 
to  make  the  diagnosis  while  the  affected  organ  is  in  situ  is  of  the  utmost 
importance,  and  for  this  reason  surgeons  should  accustom  themselves 
to  study  removed  tissue  with  great  care. 

It  is  quite  as  important  that  the  uterus,  as  well  as  the  ovary,  be 
left  in  good  position.  If  no  attention  is  paid  to  this  detail,  the  uterus 
may,  by  exerting  traction  on  the  broad  ligament,  set  up  a  disturbance 

'  Souve:   Bull,  de  la  vSoo.  Anat.  de  Paris,  November,  1907. 
'  Kawasoyp,  M.:   Zeit.  f.  Geb.  u.  Gyn.,  1912,  vol.  Ixxi,  No.s.  1  and  2. 
^  Mcllroy,  A.  L.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  July,  1912,  p.  19. 
*  Martin,  F.  H.:   Sur^..  Gyn.,  and  Obst.,  April,  1907,  p.  .501. 


THE    TREATMEXT   OF    PELVIC    INFLAMMATORY    DISEASE  299 

in  the  ovarian  circulation  or  actually  drag  the  ovary  into  a  painful 
position. 

Ovarian  Conservation  After  Hysterectomy 
Cases  in  whicii  ovarian  conservatism  is  possible  when  hysterectomy 
for  pelvic  inflammatory  disease  is  demanded  are  rare,  the  general  rule 
being  that  when  it  is  necessary  to  remove  the  uterus,  both  ova- 
ries are  so  diseased  as  to  require  their  ablation.  Indeed,  bilateral 
oophorectomy  is  usually  the  indication  for  the  hysterectom^^  Never- 
theless, occasionally  cases  may  be  encountered,  and  when  such  is  the 
case,  the  ovary  or  ovaries  should  be  left  behind.  Conservative  ovarian 
surgery  after  hystero-myomectomy  has  amply  demonstrated  the 
physiologic  success  of  this  procedure,  as  exemplified  by  the  work  of 
Polak,'  Holzback,'-  Dickinson,^  Kelly  and  Cullen,*  Konstantinides,^ 
Clark  and  Xorris,'^  and  many  others.  Polak'  states  that  the  nervous 
phenomena  are  more  marked  when  the  patient  operated  upon  is  in  good 
health,  and  that  the  post -operative  menopause  occurs  less  often  after 
total  extirpation  for  pelvic  inflammations  than  when  the  ablation  is 
performed  for  fibromyomata.  Dickinson*  observes  that  conservation 
of  ovarian  structure  after  hysterectomy  showed  80  per  cent,  of  the 
patients  to  be  free  from  disturbances  of  the  surgical  menopause.  In 
married  women  the  conservatism  showed  nearly  uniform  persistence 
of  the  sexual  desire.  Dickinson'  strongly  opposes  the  practice  of  re- 
moving normal  ovaries  when  performing  a  hysterectomy  at  or  near  the 
menopause,  on  account  of  age.  In  cases  of  pelvic  inflammations  ova- 
rian conservation  should  be  governed  bj^  the  same  rules  as  previously 
suggested.  The  maintenance  of  the  proper  blood-supply  is  of  the 
utmost  importance,  and  unless  this  can  be  obtained  and  the  ovary 
left  in  a  position  secure  from  prolapse,  its  removal  is  indicated.  The 
author's  custom  has,  in  this  respect,  been  similar  to  the  operative  pro- 
cedures recommended  by  Polak,'"  who  raises  the  ovary  well  up  and 
suspends  it  from  the  round  ligament,  especial  care  being  observed  to 
avoid  inflicting  trauma  on  the  ovary  and  to  cover  all  raw  areas.  In 
7  cases  previously  rccortled"  no  ill  effects  have  occurred,  and  the  un- 
pleasant phenomena  of  the  surgical  menopause  have  been  absent. 

'  I'oliik:  Surn.,  (lyn  ,  :in(l  Obsl..  .Inly,  1111 1. 

=  II()lzl)ack:   Arrli.  f.  (!yn..  vol.  Ixxx,  No.  •_', 

'  Dickinson:  .Surg..  (;yn.,  ami  Ohsl,,  .July,  lidl.  p.  W'.l 

'  Kelly  und  CuUen:   Myoniata  of  the  I'teriis,  fir.sl  edition,  l'.)()0. 

'  Konstantinide.**,  (1.:   Miinch.  mod.  Woehensehr.,  H»10,  No.  9,  p.  491. 

•  Clark,  J.  G.,  and  Norris,  C.  C:  Surg.,  Cyn,,  and  Oh.st.,  October,  l<.)in. 

'  Polak:  Suri;..  Cyn.,  and  Okst.,  .July,  1911. 

'Diekin.son:   SurR.,  (!yn.,  and  Olist.,  .July,  1911,  p.  99. 

»  Dickin.son:    Lor.  Hi.  "'  I'olak:   .'^urn.,  'lyn.,  and  (»li-.i,,  .July.  I'.Ml. 

"  Clark,  J.  U.,  and  .Norris,  C.  C:   SuriJ..  Cyn.,  and  Oh.^l.,  ()(t,.l,(M-,  1910. 


300  GONORRHEA    IN    WOMEN 

CONSERVATIVE  UTERINE  SURGERY 
With  our  inoreased  knowledge  of  the  function  of  the  ovaries,  and 
with  the  cognizance  that  without  these  adjuncts  the  uterus  is  a  useless 
organ,  and  that  a  better  support  to  the  roof  of  the  vagina  may  be  ob- 
tained by  a  supravaginal  hysterectomy,  most  operators  are  agreed  as 
to  the  advisability  of  performing  a  hysterectomy  whenever  a  double 
oophorectomy  is  required.  Reed'  has  recently  pointed  out  that  such 
uteri,  if  allowed  to  remain  behind,  are  frequently  the  cause  of  much 
suffering.  Giles^  found  that  in  62  cases  in  which  a  bilateral  salpingo- 
oophorectomy  was  performed  the  uterus  subsequently  gave  trouble 
in  7,  and  2  required  a  second  operation.  This  observer  presents  the 
following  table,  showing  the  atrophic  results  following  bilateral 
salpingo-oophorectomy : 

Under  Under  Over  Total 

Two  Years      Five  Years      Five  Years      Number 
Per  Cent.        Per  Cent.        Per  Cent.      of  Cases 

Utenis  and  vagina  normal 38  26.7  18  17 

Uterus  or  vagina  atropliied 31  33.0  54  20 

Uterus  and  vagina  atrophied 31  40.0  27  18 

Total 5o 

This  is  another  argument  in  favor  of  removal  of  the  uterus  when  it  is 
found  necessary  to  perform  a  double  oophorectomy. 

Kerr^  also  emphasizes  the  importance  of  removing  the  uterus  when 
a  bilateral  salpingo-oophorectomy  is  necessary.  Carmichael  and  Mar- 
shall^ found  that  in  young  animals,  when  the  ovaries  were  removed, 
the  uterus  underwent  fibrous  degeneration. 

Curetage. — A  thorough  curetage  and  iodinization  of  the  uterine 
cavity  should  precede  all  abdominal  operations  for  pelvic  inflamma- 
tory disease.  If  a  supravaginal  hysterectomy  is  to  be  performed,  this 
procedure  lessens  the  danger  of  infection  when  the  cervix  is  cut  across. 
When  the  uterus  is  to  be  spared,  curetage  and  the  application  of  iodin 
not  only  increase  the  hkelihood  of  a  complete  cure,  but  also  lessen  the 
dangers  of  infection  from  a  uterus  often  the  seat  of  a  chronic  endo- 
metritis, to  the  adnexa,  which  are  not  to  be  removed  at  operation. 
Stone''  not  only  employs  iodin  routinely  in  the  uterine  cavity,  but  also 
irrigates  the  Fallopian  tube  through  the  abdominal  incision  when  the 
oviduct  is  to  be  saved.  He  states  that  no  unusual  reaction  follows 
irrigation  of  the  tubes  with  a  solution  composed  of  25  or  50  per  cent. 

'  Reed:   New  York  Med.  Jour.,  March  5,  1910. 

=.Giles,  A.  E.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  March  and  .\pril,  1910. 

«  Kerr,  J.  M.  M.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  1910,  vol.  xvii,  p.  4.58. 

<  Carmichael,  E.  S.,  and  Marshall,  F.  A.  F.:  Brit.  Med.  Jour.,  1907.  vol.  ii,  p.  1.572. 

'Stone:    The  Virginia  Medical  Semi-Monthly,  June  7,  1912,  p.  105. 


A 


THE  TREATMENT  OF  PELVIC  INFLAMMATORY  DISEASE      301 

of  the  tincture  of  iodin,  but  that  there  is,  rather,  diminished  pain. 
Bovee'  is  a  strong  advocate  of  the  employment  of  iodin  in  the  uterine 
cavity  prior  to  abdominal  section. 

The  CoNDrxioN  of  the  Vermiform  Appendix  in  Cases  of  Pelvic  Perxtgnitis 
The  exact  relationship  existing  between  the  vermiform  appendix 
and  the  right  uterine  adnexa  is  difficult  to  determine  accurately.  The 
clinical  fact  that  the  appendix  is  frequently  secondarily  involved  in 
cases  of  pelvic  inflammatory  disease  is  well  known.  The  converse 
occasionally  takes  place,  as  observed  by  Watkins.-  As  regards  the 
appendiculo-ovarian  or  dado's  Ugament,  little  doubt  remains  as  to 
the  existence  of  this  structure.  It  is,  however,  in  the  author's  ex- 
perience, far  from  constant,  and  indeed  the  cases  in  wliich  it  can  posi- 
tively be  demonstrated  constitute  the  minority.  When  it  is  present, 
it  appears  merely  as  a  redupUcation  or  thin  fold  in  the  loose  peritoneum 
of  the  right  iliac  fossa.  Deaver  and  Testu,^  Treub,  Dutilh,  Olshausen, 
Kronig,  and  Diiderlein''  refer  to  Clado's  ligament  as  a  distinct  ana- 
tomic entity,  and  believe  that  this  structure  can  be  regarded  as  a 
causative  factor  in  the  production  of  tubal  disease  compU  eating  ap- 
pendicitis. Kelly  and  Hurdon^  and  Hartmann,^  while  admitting  the 
occasional  presence  of  a  thin  fold  of  peritoneum  which  connects  the 
cecum  or  meso-appendix  with  the  infundibulopelvic  ligament,  posi- 
tively deny  that  this  structure  is  ever  a  vascular  or  a  lymph  com- 
munication between  the  ovary  and  the  vermiform  appendix,  and  this 
is  the  attitude  taken  by  the  majority  of  the  present-day  anatomists. 
Hyde^  explains  the  frequent  inflammatory  lesions  of  the  vermiform 
appendix  found  in  connection  with  pelvic  inflammatory  disease  on  the 
ground  of  gravity,  and  believes  that  this  plays  an  important  part  in 
producing  such  conditions.  Increased  peristalsis,  the  different  bodily 
po.stures,  a  loaded  cecum,  a  dislocated  appendix,  enteroptosis,  and  a 
long  appendix  with  a  correspondingly  long  meso-appendix,  combined 
with  gravity,  Hyde*  concludes,  simply  bring  the  appendix  and  adnexum 
into  juxtaposition,  whereas  inflammatory  lesions,  present  in  either, 
with  the  localized  peritonitis,  arc  responsible  for  the  adhesion  of  the 
one  to  the  other. 

Of  late  years  many  operators  have  made  a  practice  of  perfcjrming 

'  l5ovi5c,  J.  W.:  .Vincr.  Jour.  Med.  .\s,soc.,  July  27,  1912,  p.  2.'>2. 
-  Watkins:  .\mer.  Jour.  Obst.,  1909,  vol.  lix,  p.  03.5. 

'  Dcavor  and  Testu;  Quoted  by  Hyde,  C.  R.:  Ainer.  Jour.  Obst.,  June,  1911,  p.  1059. 
'  Trciil),  Oiiiilh,  Olshausen,  Kronig,  and  Doderlcin:  Quoted  by  Jones,  H.  M.:  Lancet, 
July  29,  1911,  p.  29.-). 

'  Kelly  an<l  Hurdoii:   The  Vermiform  .Vppendi.x  and  its  Di.scases. 

•  Ilartmann:  (Quoted  by  Jones,  H.  M.:   Lanoet,  July  29,  1911,  p.  295. 

'  Hyde,  C".  H.:  Anier.  Jour.  Obst.,  June,  1911,  p.  10.59.  •  Hyde,  C.  R.:  Loc.  cil. 


302  GONORRHEA    IN   WOMEN 

an  appendectomy  in  nearly  all  cases  in  which  the  abdomen  is  opened, 
regardless  of  the  history  of  the  case  and  the  macroscopic  appearance 
of  the  appendix.  Von  Rosthorn'  has  pointed  out  the  fact  that  there 
is  no  other  class  of  cases  in  which  the  appendix  is  so  likely  to  be  dis- 
eased as  in  pelvic  peritonitis.  Pankow-  has  examined  150  vermi- 
form appendices  from  Kronig's  clinic,  which  were  removed  in  the 
course  of  gjaiecologic  operations,  and  has  found  1 13  diseased.  Hermes, 
in  75  cases,  found  the  appendix  diseased  in  53,  and  noted  this  condi- 
tion more  commonly  in  multiparse  than  in  primiparse.  Robb,^  under 
similar  conditions,  removed  218  appendices  and  found  209  diseased. 
Legueu*  states  that  of  17  appendices  removed  during  the  course  of 
a  right-sided  or  a  double  salpingectomy  for  salpingitis,  16  presented 
definite  lesions,  15  of  these  being  a  peritoneal  or  subperitoneal  inflam- 
mation, acute  in  character,  and  evidently  occurring  by  way  of  the 
lymphatics. 

In  the  University  Laboratory  of  Gynecologic  Pathology  there  are 
327  appendices  that  were  removed  coincidentally  with  operations  for 
pelvic  peritonitis;  of  these,  macroscopic  examinations  showed  207 
diseased,  whereas  histologic  examination  showed  246  inflamed.  The 
entire  series  presents  the  following  results:  Normal  appendices,  81; 
peri-appendicitis,  100;  chronic  appendicitis  (various  forms).  111;  con- 
cretion in  appendix,  33;  primary  carcinoma  of  the  appendix,  3.  In 
quite  a  definite  proportion  of  these  appendices  disease  could  not  be  de- 
tected macroscopically,  whereas  in  none  of  the  cases  of  cancer  was  the 
nature  of  the  condition  suspected  until  the  organs  reached  the  labora- 
tory. The  author  believes  that  in  all  conservative  or  radical  operations 
for  pelvic  inflammatory  disease  appendectomy  should  be  performed 
unless  there  are  unusual  operative  difficulties  or  the  patient's  general 
condition  is  such  that  a  few  minutes'  adtlitional  anesthesia  would  be 
hazardous.  Even  normal  appendices,  if  not  remo^'ed,  will  frequently 
cause  subsequent  trouble.  In  the  Gynecologic  Department  of  the 
University  Hospital  we  have  been  forced  to  operate  on  not  a  few  cases 
in  which  the  appendix  had  not  been  removed  at  a  pre\-ious  operation, 
and  had  subseciuently  become  adherent  or  inflamed. 

IMMEDIATE  MORTALITY  OF  CONSERVATIVE  SURGERY 
That  the  radical  operations  carry  with  them  a  higher  mortaUty 
than  the  conservative  operations  cannot  be  doubted.     The  following 

'  Von  Rosthoin,  A. :  Monats.  f.  Geb.  u.  Gyn.,  September,  1909,  vol.  xxx,  No.  3. 
-  Pankow:   Beitrage  zur  Geb.  u.  Gyn.,  vol.  xiii.  No.  1. 
'  Robb,  H.:  Trans.  Amer.  Gyn.  Soc,  Philadelphia,  1906,  vol.  xxxi,  p.  .331. 
^Legueu:  La  Gyndoologie,  1911,  vol.  xv,  p.  14.5. 


I 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE 


303 


results,  gathered  from  statistics  from  various  sources,  bear  out  this 
statement : 

STATISTICS  COLLECTED  FROM  VARIOUS  SOURCES 
Consecutive 

Conservative  Deaths           Percentage 
Operations                                          of  Deaths 

Manton' 100  0  0.0 

Robins= 20  0  0.0 

Simpson' 475  4  0.8 

Giles^ 132  4  3.0 

Dudley^ • 858  9  I.O 

Brothers^ 160  2  1.2 

Browiv 10  0  0.0 

Jewett,  H.« 32  2  6.2 

Gynecologic  Clinic,  University  Hospital' 321  7  2.1 

Total 2108  28  1.3 

An  analysis  of  our  statistics  shows  that  of  the  7  deaths,  2  died  of 
pneumonia  and  that  2  were  nearly  moribund  at  the  time  of  operation, 
one  dying  on  the  table  and  the  other  within  a  few  hours,  both  having  had 
general  peritonitis  before  the  operation.  One  case  died  of  obstruction; 
one  of  intestinal  atony,  and  one  of  general  post-operative  peritonitis. 

Martin'"  presents  the  following  statistics  from  the  Birmingham 
Hospital  for  Women : 


Unilateral  oophorectomy 

Bilateral  oophorectomy 

Unilateral  salpiiiKeetomy 

Bilateral  salpingectomy 

Vapinal  incision 

VarioiLs  eonser\'ative  operations  on  the  appendages, 
such  a-s  ovarian  resection,  relief  of  adhesions,  etc. .  .  . 


122 

263 

36 


0.0 
0.0 
1.6 
3.0 
0.0 


END-RESULTS  OF  CONSERVATIVE  SURGERY 

Tlic  chief  object  to  he  attained  in  all  forms  of  surgery  is  to  cure  the 
patient  with  as  little  ri.sk  as  possible.  The  possibility  of  relieving  the 
immediate  troul)le,  but  in  doing  so  superimposing  a  worse  condition 

'  Manton,  W.  P.:  Trans.  Amer.  Gyn.  Soc,  Philadelphia,  lOOd.  vol.  xxxi,  p.  l'J7. 
-  l{ol)ins,  ('.  K.:  Old  Dominion  Jour.  Med.  and  Surg.,  Richmond,  lilOS,  vol.  vii,  p.  18"). 
'  Simpson:  Jour.  .Vmer.  Med.  Assoc.,  1909,  No.  15,  vol.  liii,  p.  1175. 
'  Gilex,  A.  K.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  March  and  April,  I'.tld. 
'•  Dudley,  A.  P.:  Jour.  .\mer.  Med.  Assoc,  vol.  xli.  No.  24,  p.  1446. 
"  Brothers,  A.:  Jour,  .\nier.  Med.  .\ssoc.,  February  22,  190S,  p.  505. 
'  Brown,  G.  V^  A.:    Jour.  Michigan  Med.  .\.ssoc.,  Detroit,  .Scptcuiljcr,  I'JU.S,  vol.  vii, 
p.  44!l. 

» Jewett,  H. :  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  1907,  p.  312. 

•Clark,  J.  G.,  and  Norris,  C  C:  Surg.,  Gyn.,  and  Obst.,  October,  1910. 

">  Martin,  C.:   Brit.  Med.  Jour.,  October  26,  1912,  p.  1110. 


304  GONORRHEA   IN   WOMEN 

than  that  from  which  the  patient  originally  suffered,  has  previously 
been  dwelt  upon.  Although  the  results  may  be  good  at  the  time  of 
discharge  from  the  hospital,  it  by  no  means  follows  that  the  patient 
will  henceforward  suffer  no  ill  effects  from  the  operation  or  have  no 
recurrence  of  the  original  disease.  The  latter,  possibly,  is  particularly 
likely  to  occur  in  conservative  operations  for  pelvic  inflammatory 
disease.  The  following  are  some  of  the  end-results  obtained  in  this 
class  of  cases  by  other  operators. 

Giles'  cured  120  of  132  cases. 

Polak-  cured  106  of  300  cases. 

Robins'  had  20  cases  and  cured  20  cases. 

In  our  series  of  191  cases,  140  were  cured,  40  improved,  and  11 
showed  no  improvement.  In  these  cases  only  such  patients  were 
classed  as  cured  as  evinced  no  symptoms.  No  cases  are  included  that 
were  operated  on  during  the  past  year,  an  important  point  in  compiling 
statistics  such  as  these,  for  by  including  recent  cases  recurrences  cannot 
be  known.  The  fact  that  removal  of  one  ovary  has  a  tendency  toward 
diminishing  the  amount  and  duration  of  menstruation  and  establishing 
a  somewhat  earlier  menopause  than  in  the  case  of  a  patient  possessing 
both  these  organs  has  previously  been  dwelt  upon.  In  a  certain  pro- 
portion of  cases,  however,  in  which  a  unilateral  oophorectomy  is  per- 
formed, menorrhagia  or  metrorrhagia  results.  Brothers^  reports  this 
condition  in  14  of  his  66  cases.  The  symptom  is  usually  transitory, 
and  is  probably  due  to  disturbance  of  the  vasomotor  centers  and  of  the 
entire  genital  tract,  the  cycle  of  which  centers  about  the  ovaries. 
In  our  series  irregular,  profuse  menstruation  was  present  for  a  short 
time  in  97  cases,  but  after  one  year  only  9  cases  suffered  from  this  con- 
dition, whereas  10  additional  patients  complained  of  irregularities 
without  mentioning  the  character  of  the  flow. 

In  this  connection  the  work  of  Vertes^  is  especially  interesting. 
This  investigator  reports  the  results  of  his  observations  in  a  series  of 
67  cases  in  which  one  or  both  ovaries  were  removed,  the  uterus  being 
allowed  to  remain.  In  none  of  the  cases  was  vaginal  drainage  em- 
ployed, nor  were  any  cases  of  extra-uterine  pregnancy  included,  so 
that  in  no  instance  would  extraneous  features  be  called  into  play. 
Vertes'  conclusions  are  as  follows:  If  the  interval  between  the  last 
menstrual  period  and  a  unilateral  oophorectomy  is  longer  than  twelve 
or  thirteen  days,  then  bleeding  which  subsequently  appears  may  be 

'  Giles,  A.  E.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  March  and  April,  1910. 

2  Polak,  J.  O,:  Jour.  Amer.  Med.  Assoc,  October  23,  1909,  p.  1382. 

'  Robins,  C.  R.:  Old  Dominion  Jour.  Med.  and  Surg.,  Richmond,  1908,  vol.  vii,  p.  185. 

*  Brothers,  A.:  Jour.  Amer.  Med.  Assoc.,  February  22,  1908,  p.  595. 

5  Vertes,  O.:   Gyn.  Rund.,  1912,  vol.  vi,  Nos.  8  and  9. 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  305 

regarded  as  a  predisposition  to  a  menstrual  flow,  and  usually  proceeds 
with  the  loss  of  a  less  amount  of  blood  than  during  a  normal  menstrual 
period.  If  the  interval  between  the  last  menstruation  and  the  opera- 
tion is  less  than  twelve  days,  then  the  post-operative  menstrual  flow 
will  be  subject  to  delay.  This  circumstance  may  be  explained  by  the 
fact  that  the  function  of  the  extirpated  ovary  must  be  taken  up  by 
the  organ  on  the  other  side,  but  delay  becomes  progressively  lessened 
until  the  remaining,  ovary  has  completely  adjusted  itself  to  the  in- 
creased function.  If  the  ovary  which  contains  a  maturing  Graafian 
follicle  has  been  left  behind  at  the  time  of  operation,  the  first  post- 
operative period  will  appear  at  the  normal  time,  and  the  delayed  flow 
will  manifest  itself  only  in  subsequent  periods.  After  a  bilateral 
oophorectomy  a  normal  menstrual  period  may  appear  subsequently  to 
the  operation  if  the  interval  between  the  last  period  and  the  operation 
does  not  exceed  thirteen  or  fourteen  days. 

PREGNANCIES  RESULTING  AFTER  CONSERVATIVE  SURGERY 
One  of  the  greatest  advantages  of  conservative  operations  over 
hysterectomy  is  the  possibihty  offered  these  patients  of  subsequently 
becoming  pregnant;  even  in  patients  who  do  not  conceive,  the  possi- 
bility of  childbirth  is  never  positively  withdrawn  from  them.  The 
fact,  however,  that  many  of  these  cases  do  conceive  is  well  known. 
Giles'  found  that  of  his  patients  who  were  married  and  under  forty 
years  of  age  at  the  time  of  operation,  25  per  cent,  became  pregnant 
and  went  to  term.  The  19  women  who  had  full-term  pregnancies 
bore  25  children,  and  5  other  patients  had  miscarriages,  while  of 
our  own  68  cases  which  were  married  and  under  forty  years  of  age  at 
the  time  of  operation,  and  in  which  sterilization  was  not  performed 
(bilateral  salpingectomy),  17  patients  have  become  pregnant  and 
gone  to  term,  and  were  delivered  of  living  children.  Three  of  these 
17  patients  have  had  two  children  each,  while  one  has  borne  three. 
In  none  of  the  labors  was  anything  more  required  than  low  forceps. 
In  the  series  of  68  cases  in  which  pregnancy  was  possible,  in  adtlition 
to  the  22  children  born  there  were  7  miscarriages,  3  of  those  occurring 
among  the  1 7  women  who  had  borne  children.  A  peculiar  case  of  preg- 
nancy, not  included  in  the  for(>going  group,  occurred  among  our  cases, 
and  demonstrated  the  tendency  of  the  Fallf)pian  tube  to  become 
fiatcnt  if  it  is  simply  tied  off  without  excising  the  intramural  jiortion. 
This  patient  was  operated  upon  for  double  i)us-tubes  of  unusual  size. 
Both  ovaries  were  den.sely  adherent  and  one  was  much  enlarged,  due 
to  the  presence  of  a  retention  cyst.     Both  tubes  and  the  cystic  o\ary 

'  Giles,  A.  ]•:.:   Jour.  Ob.Kt,  ami  (Ivii.  of  Urit.  Kmp.,  March  and  April,  1!)10. 
20 


306  GONORRHEA    IN   WOMEN 

were  removed.  The  patient  took  the  anesthetic  badly,  and  in  order  to 
save  time  the  tube  was  tied  off  in  the  old-fashioned  way  on  the  side 
upon  which  the  salpingo-oophorectomy  was  performed.  Convalescence 
was  uninterrupted.  Menstruation  was  regular,  but  rather  scanty. 
Two  years  after  the  operation  the  patient  became  pregnant,  and  sub- 
sequently gave  birth  to  a  full-term,  healthy  child. 

Numerous  statistics  relating  to  pregnancy  following  conservative 
pelvic  surgery  are  on  record,  but  most  of  these  are  misleading,  because 
important  details,  such  as  the  proportion  of  married  patients,  the 
age  of  the  women,  the  amount  of  time  that  elapsed  between  operation 
and  the  compiling  of  the  statistics,  etc.,  are  lacking. 

Number  of  Cases         Subsequent  Per 

Reported  Pregnancies  Cent. 

Polak' 240  26  10.0 

Butler 50  1  2.0 

Hyde= 21  1  .3.8 

Manton= 41  6  14.0 

Robb,  H 419  0  0.0 

Baldwin,  L.  G.-'  (quoted  by  Hyde) 99  0  0.0 

Dickinson .50  0  0.0 

Jewett* 67  0  0.0 

Brothers^ 100  0  0.0 

Brown,  G.  V.  A.' 10  1  10.0 

Dudley,*  after  carefully  reviewing  the  after-histories  of  2168  cases, 
came  to  the  conclusion  that  at  least  10  per  cent,  become  pregnant, 
whereas  Hyde,'-'  in  summing  up  a  large  series  of  his  own  and  of  other 
operators'  cases,  believes  that  not  more  than  5  per  cent,  become 
pregnant.  This  latter  proportion  should  probably  be  at  least  doubled 
if  we  take  into  consideration  the  age  and  condition  of  the  patients  from 
whom  these  statistics  are  computed,  for  it  is  obviously  incorrect  to 
include  cases  of  women  past  forty  or  spinsters  in  these  figures.  It  is 
interesting  to  note  that  in  Polak's'"  series  of  cases,  all  of  which  were  at 
the  child-bearing  age,  17  of  the  26  pregnancies  followed  the  ablation 
of  the  ovary  on  one  side  and  the  resection  of  the  opposite  organ. 

1  Polak,  .1.  O.:  Jour.  Amer.  Med.  Assoc,  October  23,  1909,  p.  1392. 

2  Hyde,  C.  R.:  Amer.  Jour.  Obst.,  August,  1907,  vol.  Ivi,  No.  2,  p.  14.5. 

'  Manton,  W.  P.:  Trans.  Amer.  Gyn.  Soc,  Philadelphia,  1906,  vol.  .\.\xi,  p.  197. 

*  Baldwin,  L.  G.:  Amer.  Jour.  Obst.,  1907,  vol.  Iv,  p.  203. 

» Jewett,  H.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  1907,  p.  312. 
'  Brothers,  A.:  Jour.  Amor.  Med.  A.ssoc.,  February  22,  1908,  p.  .595. 
~  Brown,  G.  V.  A.:    Jour.  Michigan  Med.  A.ssoc,  Detroit,  September,  190S,  vol.  vii, 
p.  449. 

*  Dudley,  A.  P.:  Jour.  .\mer.  Med.  Assoc,  vol.  xli,  No.  24,  p.  1446. 

5  Hyde,  C.  R.;  Amer.  Jour.  Obst.,  August,  1907,  vol.  Ivi,  No.  2,  p.  145. 
'"  Polak,  J.  O.:  Jour.  Amer.  Med.  Assoc,  October  23,  1909,  p.  1382. 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  307 

POSSIBILITIES   OF   ECTOPIC  PREGNANCY  FOLLOWING 
CONSERVATIVE  OPERATIONS 

Giles'  was  one  of  the  first  writers  to  draw  attention  to  the  likeUhood 
of  ectopic  gestation  occurring  subsequently  to  a  conservative  opera- 
tion of  the  uterine  adnexa.  Of  his  patients,  7  subsequently  became 
pregnant  ectopically,  whereas  Polak-  reports  one  cornual  pregnancy 
following  a  radical  salpingectomy.  In  our  series  of  68  cases  2  women 
were  subsequently  operated  on  for  tubal  pregnancy.  These  figures 
bear  out  the  theory  that  the  chief  etiologic  factor  in  the  production 
of  tubal  pregnancy  is  pelvic  peritonitis.  If  tubal  pregnancy  is  partic- 
ularly prone  to  follow  conservative  operations, — and  these  figures 
indicate  that  it  is, — this  factor  must  be  taken  into  consideration  in  all 
conservative  operations  on  married  women  of  child-bearing  age. 

PROPORTION   OF   CASES   REQUIRING  A  SECONDARY  OPERATION   AFTER  A 
CONSERVATIVE  OPERATION 

The  fact  that  a  very  definite  proportion  of  pelvic  inflammatory 
cases  subjected  to  conservative  operation  require  a  second  operation 
for  the  recurrence  of  an  old  disease,  or  the  further  progress  of  the  in- 
flammation into  organs  hitherto  unaffected,  is  the  strongest  argument 
in  favor  of  the  radical  operation.  The  frequency  with  which  the  gono- 
coccus  is  found  as  the  infective  agent  in  these  cases,  and  also  its  per- 
sistence, together  with  the  advantages  to  be  derived  from  delayed 
operation,  have  previously  been  dwelt  upon;  but,  nevertheless,  even 
with  the  most  careful  proliminary  treatment  and  the  most  prudent 
selection  of  cases  a  certain  percentage  of  patients  will  require  a  second- 
ary operation,  as  may  be  seen  from  the  following  table: 

Cases  with 

NcMBER  OF  Cases  Secondary 

Reported  Operations 

Polak= 300  41 

Baldwin' 99  1 

.Icwett' 67  6 

Oirkinson 50  4 

.ludd 50  2 

.Manton' 100  3 

( !ilfs« 52  4 

Hobl)' 419  10 

Krotlicrs* 85  0 

(  raKin.  E.  B 33  1 

( "lark  and  Norris' 190  7 

'  Giles,  A.  K.:  .lour.  Ob.st.  and  (iyn.  of  Brit.  ICmp.,  March  and  .\pril,  1010. 
'  I'olak,  J,  <).:   .lour.  Amor.  Med.  A.si*oc.,  October  23,  1909,  p.  1382. 
'  Baldwin,  L.  G.:  Amor.  Jour.  Obst.,  1907,  vol.  Iv,  p.  203. 
« Jcwctt:  Jour.  Obst.  and  fJyn.  of  Brit.  Emp.,  1907,  p.  312. 
»  Mnnton,  W.  P.:  Trans.  Amcr.  (iyn.  Soc,  Philadelphia,  1900,  vol.  xxxi,  p.  197. 
•Giles,  A.  E.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  March  and  April,  1910. 
'  Uobb,  H.:  Amer.  Jour.  Obst.,  1907,  vol.  Iv.     Thirteen  other  ca.se.s,  however,  were  ini- 
dcr  observation  for  symptoms,  10  of  which  were  subsequently  cured  without  operation. 
'  Brothers,  A.:  Jour.  Amer.  Med.  A.s.soc.,  February  22,  19()H,  p.  .59.'). 
•Clark,  J.  G.,  and  Norris,  C.  C:  Sui>?.,  Gyn.,  and  Ob.st.,  October,  1910. 


308  GONORRHEA    IN   WOMEN 

Diihrssen/  from  an  experience  of  1000  cases,  believes  that  not  more 
than  2  per  cent,  require  a  second  operation. 

Thus  we  find  that  out  of  a  total  of  1445  cases  of  various  operators, 
85,  or  5.8  per  cent.,  require  a  secondary  operation,  and  this  is  not  taking 
into  consideration  the  fact  that  many  of  these  cases  were  not  subjected 
to  preUminary  treatment  prior  to  operation.  The  proportion  of  cases 
in  which  an  apparently  normal  tube  becomes  diseased  subsequent  to 
the  removal  of  the  appendages  of  the  opposite  side  is  difficult  to  esti- 
mate, owing  to  the  fact  that  the  majority  of  the  statistics  on  this  sub- 
ject are  based  upon  such  broad  grounds.  Giles,^  however,  has  care- 
fully followed  the  after-results  of  44  such  cases,  and  found  that  in  but 
one  did  trouble  arise.  Of  our  73  cases  in  which  operations  were  per- 
formed on  one  side,  the  opposite  tube  being  left  undisturbed,  a  second- 
ary operation  was  required  5  times.  In  3  of  the  5  cases  in  which  a 
secondary  operation  was  necessary  the  case  histories  show  that  both 
tubes  were  adherent  at  the  time  of  operation,  whereas  in  the  other  2 
cases  no  mention  is  made  in  the  histories  as  to  the  condition  of  the 
tube. 

CONCLUSIONS 

1.  With  few  exceptions  all  pelvic  inflammatory  cases  should  be 
subjected  to  a  course  of  preliminary  treatment  before  operation  is 
undertaken.  If  this  is  done,  some  will  escape  operation  entirely, 
whereas  others  can  be  operated  on  more  easily,  more  quickly,  and  with 
lower  mortality;'  and  morbidity.  A  greater  number  of  cases  will  also 
be  found  to  be  suitable  for  conservative  operation.  If  possible,  the 
patient's  temperature  and  blood-counts  should  be  normal  for  from  foiu* 
to  six  weeks  before  operation. 

2.  If  pus  is  present  and  can  easily  be  reached  without  traversing 
the  peritoneal  cavity,  it  should  be  evacuated  at  once.  In  a  small 
percentage  of  cases  the  symptoms  may  be  of  such  a  character  as  to 
preclude  the  possibility  of  delay.  Accurate  diagnosis  and  a  careful 
study  of  the  cases  will,  however,  show  that  but  a  small  proportion 
require  emergency  surgery. 

3.  The  end-results  of  salpingostomies  are,  as  a  rule,  disappointing. 
Pregnancy  rarely  takes  place,  as  the  newly  formed  ostia  quickly  become 
occluded  and  cause  a  recurrence  of  symptoms. 

4.  Conservation  of  a  grossly  normal  tube  in  the  presence  of  dis- 
eased appendages  on  the  opposite  side  offers  good  results,  especially  if 

'  Diihrssen,  M.:  Trans.  Amer.  Gyn.  Assoc,  Philadelphia,  1906,  vol.  xxxi,  p.  197  (dis- 
cussion of  Dr.  Man  ton's  paper). 

^  Giles,  A.  E.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  March  and  April,  1910. 


THE    TREATMEXT   OF    PELVIC    INFLAMMATORY   DISEASE  309 

a  course  of  preliminary  treatment  has  been  carried  out  prior  to  opera- 
tion. 

5.  Conservation  of  macroscopically  diseased  tubes  is  unsatisfac- 
tory. 

6.  Conservative  ovarian  surgery  offers  excellent  results,  provided 
that  the  ovarian  circulation  is  not  impaired  and  that  the  organ  is  left 
in  a  good  position.  This  is  strikingly  exemplified  in  our  series  of  48 
double  salpingectomies  when  one  or  both  ovaries  were  spared,  none  of 
these  cases  requiring  a  second  operation. 

7.  In  selected  cases  ovarian  resection  offers  excellent  results.  If 
a  small  amount  of  ovarian  tissue  is  left  behind,  this  will  usually  avert 
the  sudden  onset  of  the  menopause.  The  reason  that  many  resected 
ovaries  become  cystic  is  because  of  the  interference  with  the  blood- 
supply. 

8.  When  it  is  found  necessary  to  remove  both  ovaries,  a  hysterec- 
tomy should  nearly  always  be  performed.  Such  uteri  are  useless  and 
often  give  rise  to  subsequent  trouble. 

9.  If  it  is  found  necessary  to  remove  the  uterus  and  one  or  both 
ovaries  can  be  spared,  their  preservation  will  prevent  the  unpleasant 
symptoms  attending  the  artificial  menopause;  for  although  menstrua- 
tion will  cease,  the  neuroses,  which  are  the  most  distressing  symptoms 
of  the  menopause,  will  be  absent. 

10.  A  thorough  curetage  and  iodinization  of  the  uterine  cavity 
should  precede  all  abdominal  sections  for  pelvic  inflammatory  disease. 
Areas  of  infection  in  the  lower  genital  tract  should  subsequently  re- 
ceive appropriate  treatment. 

In  order  to  obtain  correct  statistics  regarding  the  after-residts  in 
these  cases  a  circular  letter- was  sent  to  each  patient.  In  those  cases 
that  failed  to  reply  a  letter  was  sent  to  the  patient's  family  physician. 
In  these  letters  special  inquiry  was  made  as  to  the  condition  of  the 
menstrual  functi(jn,  leukorrhea,  dysmenorrhea,  abdominal  pain,  preg- 
nancies, miscarriages,  operations,  or  illnesses.  Those  patients  who 
lived  in  the  city  or  who  did  not  feel  entirely  well  were  asked  to  return 
to  the  hospital  for  examination.  A  number  of  patients  complied  with 
this  request,  so  that,  in  addition  to  the  reply  to  our  circular  letter,  many 
of  our  cases  have  been  personally  examined.  No  patient  was  classed 
as  cured  unless  she  or  her  physician  considered  that  a  cure  had  been 
effected,  nor  were  any  cases  regarded  as  cured  unless  they  were  entirely 
free  from  pelvic  .symptoms.  Thus,  if  a  patient  complained  of  dys- 
menorrhea, she  was  classed  as  improved  or  unimproved,  according  to 
the  severity  of  condition.  As  has  been  shown  by  the  work  of  Marie 
Tol)ler,'  from  50  to  7.')  per  cent,  of  all  women  suffer  more  or  less  at 

'  Tdhl.  1.  M.:   Moimls.  f.  (id,,  ii.  flyn.,  l'.H)r>,  vol.  xxii,  p.  1. 


310 


GONORRHEA    IN    WOMEN 


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THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  311 

the  menstrual  periods,  and  it  seems  probable  that  some  of  the  cases  in 
the  series  under  consideration  that  were  classed  as  improved  would 
actually  compare  very  favorably  with  the  average  woman.  No  cases 
were  included  in  this  series  that  had  been  operated  upon  during  the 
past  year,  whereas  some  of  them  are  of  eleven  years'  standing.  One 
case  of  unilateral  salpingo-oophorectomy  was  well  for  two  j'ears,  when 
a  miscarriage  occurred,  and  infection  followed,  requiring  a  secondary 
operation.  This  case  was  classed  as  unimproved,  as  was  another  case 
of  unilateral  salpingo-oophorectomy  who  was  entirely  well  for  thirteen 
months,  when  trouble  recurred  requiring  a  second  operation.  A  case 
of  bilateral  salpingectomy  and  unilateral  oophorectomy  was  well  for 
two  years,  when,  while  lifting  a  heavy  weight,  the  patient  felt  something 
"give  way"  in  her  abdomen  and  a  uterine  prolap.se  resulted;  she  was 
classed  as  unimproved.  Following  one  of  the  ovarian  resections  the 
ovary  became  enlarged  to  the  size  of  a  lemon,  and  gave  considerable 
trouble.  Three  months  after  operation,  however,  it  was  not  palpable, 
and  no  symptoms  were  present.  Seven  years  after  the  operation  the 
patient  was  menstruating  regularly  and  painlessh'.  This  case  was 
classed  as  cured.  In  nearly  all  the  oases  dilatation  and  curetage  were 
performed,  together  with  a  suspension  operation;  in  some  cases 
ventral  suspension,  in  others,  the  Gilliam  operation,  and  in  the  more 
recent  cases,  the  Coffey  operation,  was  done;  ventral  fixation  was 
performed  in  some  of  the  cases  in  which  both  tubes  were  excised. 

HYSTERECTOMY  AND  BILATERAL  SALPINGO-OOPHORECTOMY  FOR 
PELVIC  INFLAMMATORY  DISEASE 

Indication.  I'ndcr  the  heading  Conservative  Uterine  Surgery 
it  was  stated  that  when  it  becomes  necessary  to  remove  both  ovaries, 
a  hysterectomy  is  indicated  in  nearly  all  cases.  It  is  true  that  Web- 
ster' and  Freund  have  utilized  the  uterus  to  cover  a  rent  in  the  pelvic 
peritoneum  or  rectum  after  the  ablation  of  both  tubes  and  ovaries. 
Further  autoplastic  surgery  has  been  reported  by  .Judct,'  (^uenu,'' 
Sneguireff,'  Summers,'  Kelly,"  and  others. 

Cases  in  which  uterine  autoplastic  surgery  are  neces.sary  are,  how- 
ever, of  extreme  rarity,  and  carefully  applied  sutures  usually  answer 
the  same  purpose,  and  offer  better  hope  of  effecting  a  permanent  symp- 
tomatic cure.     As  has  previously  been  pointed  out,  uteri,  if  l(>ft  in 

'  Wclntcr.  .1.  ('.:  (iynocoloKV  and  Aljiiominul  SiirKcry,  Kelly  and  NoMc,  vol.  i,  p.  (iJJ. 

^J^l<ll■t;   La  Rev.  dc  (lyn.  ct  do  Cliir.  Ahdoni.,  O Mili<r-.  KlOd 

'Qui'mui:    Trans.   Krcncli  .Surni'ons,   Paris,   ISiMI. 

'  SncKuircfT,  V.  T..    Klin.  Jour.,  Mo.scow,  lOOl),  \o.  I,  p    1 

'SinnnuTs:  Surg.,  Gyn.,  and  Obst.,  August,  1911. 

"Kelly,  H.  A.,  and  Noble,  C.  P.:  Gyneeology  and  .Vbdoniinal  .'^urgery,  (irsi   cililion. 


312  GONORRHEA    IN    WOMEN 

place  after  the  removal  of  both  tubes  and  ovaries,  not  infrequently  give 
rise  to  subsequent  trouble.  The  indications  for  performing  a  hyster- 
ectomy and  bilateral  salpingo-oophorectomy  have  been  extensively 
dealt  with  under  the  heading  of  Conservative  Surgery  of  the  Adnexa. 

Not  a  few  cases  will  be  observed  in  which,  on  account  of  the  extent 
of  the  disease,  no  other  form  of  treatment  can  be  considered,  and  in 
these  the  choice  of  operation  lies  between  a  supravaginal  hysterectomy 
and  a  total  removal  of  the  entire  uterus  and  cervix.  The  supravaginal 
amputation  is  the  operation  most  frequently  employed.  This  opera- 
tion is  more  easily  and  quickly  performed,  and  if  the  amputation  is 
made  at  a  low  level,  the  cervix  well  cupped  out,  the  canal  widely 
dilated,  the  mucosa  destroyed  by  the  actual  cautery,  and  the  round 
Ugaments  utilized  for  suspension  purposes,  equally  good,  if  not  better, 
results  are  obtained  in  the  majority  of  cases  than  follow  a  panhysterec- 
tomy. It  is  imperative  that  all  the  mucosa  of  the  cervical  canal  be 
destroyed.  By  retention  of  the  cervix  the  anchorage  of  the  uterosacral 
ligaments  is  retained,  which  materially  aids  in  the  suspension  of  the 
latter  structure. 

Some  surgeons  prefer  to  remove  the  cervix  in  all  cases.  Schiff man  and 
Patek^  state  that  their  panhysterectomy  cases  have  been  more  satis- 
factory than  have  been  those  in  which  the  supravaginal  operation  has 
been  performed.  The  surgeon  should,  however,  be  largely  guided  by 
the  conditions  present  in  the  individual  case.  If  cervical  leukorrhea 
has  been  a  pronounced  symptom,  and  if  this  organ  is  heavy  and  greatly 
hypertrophied  or  presents  an  extensive  laceration,  and  especially  if  a 
marked  degree  of  eversion  or  cervicitis  is  present,  a  panhysterectomy 
is  indicated. 

Several  authors  have  reported  the  appearance  of  a  bloody  flow  at 
irregular  intervals  following  supravaginal  amputation.  But  this  may 
in  most  instances  be  ascribed  to  imperfect  technic.  To  obviate  this, 
Chaput,^  after  the  removal  of  the  uterus  and  adnexa  in  the  usual  way, 
makes  an  incision  into  the  anterior  vaginal  vault,  slits  the  cervix, 
everts  it,  and  excises  the  mucosa;  he  then  sutures  it  in  its  original  form, 
and  invaginates  it  and  closes  the  vagina  above,  de  Rouville'  recom- 
mends vigorous  curetage  of  the  cervical  canal  after  supravaginal  re- 
moval of  the  uterus.  He  scrapes  out  the  canal  with  circular  sweeps  of  a 
bistoury  until  only  a  thin  shell  a  few  millimeters  tliick  remains.  The 
operation  is  then  concluded  in  the  ordinary  manner.  These  pro- 
cedures have  no  advantages  in  ordinary  cases  over  the  operation 
already  recommended. 

'  Schiffman  and  Patek:   Monats.  f.  Geb.  u.  Gyn.,  1911,  vol.  xxxiii,  p.  .310. 

^Chaput:   Rev.  de  Gyn.,  August,  1910. 

'  de  Rouville:    Rev.  Prat.  d'Obstet.  et  de  Gyn.,  Paris,  October,  1912,  vol.  xx,  No.  10. 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  313 

It  would  seem  that  the  immediate  mortahty  of  panh\'sterectomy 
should  be  slightly  greater  than  in  the  less  radical  operation,  as  in  the 
former  the  vagina  is  opened  and  the  operation  is  more  extensive.  A 
study  of  statistics,  however,  fails  to  show  any  marked  degree  of  dif- 
ference. As  a  means  of  lessening  the  dangers  of  post-operative  in- 
fection in  these  cases  de  Rouville'  recommends  sterilization  of  the  vagina 
with  iodin.  He  reports  66  hysterectomies,  of  which  40  were  sub-total 
and  26  total,  with  2  deaths,  neither  of  which  was  caused  by  infection. 

The  question  of  cancer  occurring  subsequently  in  the  cervical  stump 
is  worthy  of  consideration.  If  the  cervical  mucosa  is  destroyed  by  the 
cautery,  this  is  extremely  unlikely.  Such  cervices  atrophy,  and  malig- 
nant changes  are  of  extremely  rare  occurrence.  Among  757  supra- 
vaginal hysterectomies  performed  for  various  causes  in  the  Gyneco- 
logic Department  of  the  University  of  Pennsylvania  during  the  last 
twelve  years,  not  a  single  known  case  of  cervical  cancer  has  occurred, 
although  about  half  of  the  cases  have  been  traced.-  Giles^  asserts  that 
the  fate  of  the  cervical  stump  after  supravaginal  hysterectomy  need 
cause  no  apprehension.  Of  181  of  his  cases  not  one  showed  any  signs 
of  malignancy,  and  in  98.3  per  cent,  no  trouble  of  any  kind  was  caused 
by  the  retention  of  the  cervix.  The  immediate  mortality  in  our  series 
of  69  cases,  in  the  majority  of  which  supravaginal  hysterectomies  were 
performed,  was  5.7  per  cent.  This  includes  death  from  all  causes. 
One  case  died  of  post-operative  peritonitis,  one  of  volvulus,  and  two 
of  heart  and  respiratory  failure,  in  one  of  which  the  ether  is  believed  to 
have  been  the  contributing  cause.  Baldy^  states  that  in  a  series  of 
223  cases  of  hysterectomy  performed  by  himself  and  five  other  opera- 
tors, the  mortalitj'  was  2.68  per  cent.  It  is  not  stated  whether  this 
represents  the  total  number  of  deaths  or  is  only  the  immediate  opera- 
tive mortality.  Davis^  reports  a  series  of  22  cases  in  which  hysterec- 
tomy and  bilateral  salpingo-oophorectomy  were  performed,  in  which 
the  immediate  mortality  was  13.6  per  cent.  It  should,  however,  be 
stated  that  many  of  these  cases  were  complicated,  all  were  drawn 
from  free  patients,  and  in  all  drainage  was  employed.  A  report  from 
the  von  Herff  clinic^  showed  that  of  45  drained  cases,  the  mortality  was 
24.4  per  cent.     These  and  other  statistics  indicate  that  hysterectomy 

'  (If  Houville:    Bull,  di;  la  Soc.  d'Olistet.  de  Paris,  February,  1911. 

'Since  the  above  was  written  a  case  has  occurred.  Operation  thirteen  years  prinr  to 
the  development  of  the;  cancer. 

'  (Jiles,  A.  Iv:   Afler-rcsults  of  Abdominal  Operations,  1910,  p.  hi. 

*  Hiilciv:  Killv  and  Noble,  Gynecology  and  Abdominal  Surgery,  first  edition,  vol.  i, 
p.  C.'>I). 

'  Davis,  K.  I'.:  .-^mer.  .Jour.  Obst.,  September,  1911. 

"  l{rp<,rl  of  the  Sixth  International  Congress  of  f  )l)sletrieians  and  Cyiiccolonists,  Iler- 
lin.  .September  9  to  13,  1912. 


314  GONORRHEA    IN    WOMEN 

carries  with  it  a  greater  mortality  than  the  less  radical  operation.  Of 
the  321  cases  of  conservative  operation  previously  referred  to  from  the 
Gynecologic  Clinic  of  the  University  Hospital,  the  mortality  was  2.1 
per  cent.  This  includes  deaths  from  all  causes.  In  a  series  of  2108 
conservative  operations  performed  by  various  surgeons,  the  total 
mortality  was  only  1.3  per  cent. 

Of  31  consecutive  cases  of  hysterectomy  and  bilateral  salpingo- 
oophorectomy  for  pelvic  inflammatory  disease,  the  after-histories  of 
which  could  be  traced,  24,  or  77.4  per  cent.,  are  completely  cured,  5  are 
improved,  and  1  shows  no  improvement.  This  last  case  improved 
for  about  a  year.  Her  symptoms  were  chiefly  due  to  the  artificial 
menopause.  One  year  after  the  operation  she  had  a  stroke  of  apoplexy, 
and  has  been  in  ill  health  ever  since.  The  chief  symptoms  from 
which  the  4  improved  cases  suffered  were  constipation,  and  in  3, 
dyschesia.  The  pain  in  2  of  these  cases  was  apparently  due  to  ad- 
hesions. All  these  patients  were  of  a  constipated  habit  before  opera- 
tion. Twelve  of  the  24  cured  cases  suffered  from  constipation  before 
the  operation,  but  are  now  normal.  In  none  of  the  cases  was  there  any 
pathologic  leukorrhea  following  the  operation. 

Giles'  summarizes  the  results  of  18  cases  of  total  extirpation  for 
inflammatory  disease,  and  finds  that  a  very  marked  improvement 
occurred  in  17  of  his  cases,  and  also  that  in  many  of  the  women 
the  sexual  desire  remained  unaltered.  In  only  4  of  the  18  cases, 
however,  has  the  operation  been  performed  more  than  two  years 
before  the  report  was  issued.  That  the  sexual  appetite  is  not  im- 
mediately lost  after  a  panhysterectomy  is  well  known.  The  excision 
of  appendages  the  seat  of  inflammatory  disease  often  removes  the 
cause  of  a  preexisting  dyspareunia,  and  patients  state  that  following  the 
operation  sexual  desire  is  increased.  The  proportion  of  cases  in  which 
sexual  desire  is  strong  five  years  after  the  removal  of  both  ovaries  is 
extremely  small.  In  22  of  the  31  cases  of  hysterectomy  and  bilateral 
salpingo-oophorectomy  the  after-histories  of  which  we  have  been 
able  to  obtain,  the  vermiform  appendix  was  removed  at  the  time  of  the 
hysterectomy.     Fifteen  of  the  appendices  were  diseased. 

DRAINAGE  IN  CASES  OF  PELVIC  INFLAMMATORY  DISEASE 
The  same  indication  for  drainage  exists  in  cases  of  pelvic  inflam- 
matory disease  as  exists  in  operations  for  other  pelvic  lesions.  The 
old  dictum  of  "when  in  doubt,  drain,"  has  been  reversed,  so  that  now 
we  say,  "when  in  doubt,  do  riot  drain."  The  small  proportion  of  cases 
that  require  drainage  may  be  largely  accounted  for  by  the  generally 

'  Giles,  A.  E.:   After-results  of  Abdominal  Operations,  1910.  p.  198. 


1 


THE    TREATMENT    OF    PELVIC    INFLAMMATORY    DISEASE  315 

adopted  system  of  not  operating  upon  acute  cases  and  by  an  improved 
operative  technic.  The  use  of  the  round-pointed  needle  and  of  cat- 
gut has  practically  done  away  with  the  employment  of  a  gauze  pack  to 
control  hemorrhage.  At  the  University  Hospital  the  inflammatory 
cases  that  are  drained  are  those  in  which,  for  some  reason,  it  has  been 
found  impossible  to  remove  the  entire  abscess-sac,  or  when  it  has  been 
necessary  to  leave  behind  a  large  amount  of  lymph.  Drainage  is  also 
occasionally  employed  in  those  rare  cases  in  which  the  small  intestine, 
rectum,  sigmoid  flexure,  urinary  bladder,  or  ureter  have  been  severely 
injured.  Under  such  circumstances  care  must  be  observed  to  avoid  too 
tight  packing  or  placing  the  gauze  too  near  the  defective  hollow  viseus. 
If  the  drain  is  placed  in  direct  apposition  to  the  stitches,  an  intestinal 
fistula  is  likely  to  occur.  The  plan  should  be  to  have  the  drainage 
sufficiently  near  the  suspected  area  to  guide  away  any  leakage  that 
may  occur,  but  not  to  come  in  immediate  contact  with  the  stitches. 
Such  cases  are  very  infrequent.  In  pelvic  operations  the  operator  has 
the  choice  of  two  routes  of  drainage — the  abdominal  and  the  vaginal. 
Unless  contraindicated,   the  vaginal  route  offers  many  advantages. 

In  1897  Clark'  stated  that  "if  the  pelvis  is  to  be  drained,  the  vag- 
inal route  is  preferable :  the  dangers  of  infection  are  no  greater,  and  the 
dependent  pockets  in  the  pelvis  can  be  drained  much  more  effectively 
by  this  means."  Olshausen'  summarizes  his  opinion  as  follows: 
"  In  doubtful  cases  of  deep-seated  pelvic  suppuration  in  women  vaginal 
drainage  is  more  reasonable  than  suprapubic." 

The  material  selected  for  drainage  is  usually  sterile  gauze,  and  in 
some  cases  combinations  of  gauze  and  soft  rubber.  For  vaginal  drain- 
age Bovee'  employs  a  soft-rubber  tube,  one-half  inch  or  more  in  diam- 
eter. The  upper  end  of  the  tube  had  two  lateral  arms,  each  one  inch 
in  length,  that  overlap  the  uterosacral  ligaments.  These  prevent  the 
expulsion  of  the  tube.  Silk  has  been  advocated  by  some  authorities; 
the  author  has  had  no  personal  experience  with  this  material. 
Among  the  last  100  cases  operated  upon  for  pelvic  inflammatory 
disease  in  the  (lynecologic  Department  of  the  University  Hospital, 
drainage  has  been  employed  once.  In  all  cases  when  the  culdesac 
drainage  is  employed,  the  vaginal  opening  should  be  a  free  one. 
When  gauze  drainage  is  effected  through  the  vagina,  the  custom 
at  the  University  Hospital  is  to  start  the  removal  of  it  on  the 
fifth  day,  and  have  the  gauze  entirely  removed  by  the  seventh  daj'. 
liepacking  is  not  neces.sary,  and  is,  indeed,  dangerous,  because  of  the 

'  Clark,  J.  {'■.:  .\mor.  Jour.  Obst.,  1897,  vol.  xxxv,  p.  (i.'id. 

■Olshausen:  Zeit.  f.  (lob.  u.  Oyn.,  vol.  xviii,  No.  2. 

'  HoviV,  .1.  W.:  .Jour.  Amcr.  Med.  .\ssoc.,  .luly  27,  1012.  p.  2.->l. 


316  GONORRHEA    IN    WOMEN 

possibilities  of  infection  and  breaking  up  of  adhesions.  When  tubal 
drainage  is  employed,  vaginal  irrigation  may  be  given  on  the  second  or 
third  day,  but  care  must  be  taken  that  no  force  is  used,  the  idea  being 
only  to  wash  away  discharges;  adhesions  must  not  be  broken  up.  To 
obtain  a  wide  opening  for  drainage  v.  Toth^  advocates  splitting  through 
the  entire  length  of  the  posterior  cervical  wall  after  performing  an 
ordinary  supravaginal  hysterectomy.  The  incision  is  carried  along  the 
posterior  vaginal  wall  for  a  greater  or  less  distance,  depending  upon 
circumstances.  Two  sutures  are  introduced  at  each  vaginal  edge  to 
arrest  hemorrhage,  and  two  sutures  are  placed  on -each  side  of  the 
cervix  through  the  thickness  of  the  wall.  The  outer  parts  of  the  broad 
Ugaments  are  closed  in  the  usual  way,  and  the  anterior  peritoneal  flap 
is  drawn  across  and  united  to  the  cervix  along  the  isthmal  aspect.  If 
desired,  the  pelvis  can  be  shut  off  from  the  drainage  tract  by  bringing 
the  sigmoid  flexure  across  and  suturing  it  to  the  anterior  peritoneal 
flap.  We  see  little  advantage  in  thus  splitting  the  cervix,  and  believe 
that  a  wide  lateral  incision  through  the  culdesac  is  preferable.  The 
utilization  of  flaps  of  peritoneum,  or  even  the  sigmoid  flexure  to  wall 
off  the  drainage  tract  from  the  general  peritoneal  cavity  is  an  excellent 
procedure,  and  has  for  years  been  utilized  in  certain  cases  in  the 
Gynecologic  Clinic  at  the  University  Hospital. 

CORPUS  LUTEUM  ORGANOTHERAPY  FOR  THE  ARTIFICIAL  MENOPAUSE 
The  distressing  symptoms  accompanying  the  artificial  menopause 
that  so  frequently  follows  the  removal  of  both  ovaries  have  previously 
been  dwelt  upon.  That  the  ovaries  elaborate  an  internal  secretion, 
and  that  the  removal  of  these  organs  is  the  cause  of  the  artificial  meno- 
pause, is  now  a  well-established  fact.  By  experimental  work  it  has 
been  determined  that  this  secretion  originates  in  the  corpus  luteum 
(Frankel-  and  many  others).  The  ovarian  secretion  appears  to  act 
in  conjunction  with  the  secretion  of  other  ductless  glands.  The  re- 
moval of  the  corpora  lutea  in  many  cases  produces  general  disturbances, 
such  as  proHf  eration  of  the  cells  of  the  islands  of  Langerhans  (Rebaudi^) , 
changes  in  the  hypophysis  (Giorgi''),  disturbances  of  the  thyroid 
(Rogers'"),  and  many  other  widely  divergent  results.  CoUard  and 
Huard*  state  that  because  of  the  close  relationship  existing  between  the 
ovary  and  the  thyroid  it  is  advantageous  to  combine  these  two  extracts. 

'  V.  Toth:  Zent.  f.  Gyn.,  1912,  No.  2. 

2  Fiankel,  L.:  Arch.  f.  Gyn.,  1903,  vol.  Ixviii,  p.  438. 

'  Rebaudi:  Zent.  f.  Gyn.,  1908,  No.  41. 

■*  Giorgi :  Ginecologia,  1906,  vol.  iii,  p.  72.5. 

'  Rogers,  J.:  Jour.  Anier.  Med.  Assoc,  1912,  vol.  lix,  No.  9,  p.  702. 

Tollard  and  Huard:   Thfee  tie  Paris  (I'Obstetrique),  1912. 


THE    TREATMENT   OF    PELVIC    INFLAMMATORY    DISEASE  317 

That  the  disturbances  produced  by  the  removal  of  both  ovaries 
vary  widely  in  different  individuals  is  also  certain;  some  patients  suffer 
but  little,  whereas  in  others  general  nervous  manifestations  are  marked. 
It  would  seem  that,  upon  theoretic  grounds,  the  administration  of 
corpus  luteum  extract  to  those  patients  who  have  been  deprived  of 
their  ovaries  as  a  result  of  surgical  intervention  during  their  active 
sexual  life  should  be  of  great  benefit.  Frankel,^  in  1910,  published  the 
results  of  an  extensive  series  of  experiments  on  this  subject.  In  90 
per  cent,  of  his  cases  the  flushes  and  nervous  symptoms  of  the  artificial 
menopause  were  relieved.  Burnam-  has  more  recently  reported 
equally  good  results.  Mayo,^  Clark,^  Litzenberg,^  Mainzer,^  de 
Camboulas,"  Drevet,'  Hill,^  and  Godart'"  have  also  reported' good 
results  with  this  preparation  in  tliis  class  of  cases.  No  serious  ill 
effects  follow  the  administration  of  corpus  luteum  extract  by  mouth, 
but  Villemin,"  Ferroni,'-  Lambert,"  and  others  have  shown  that  when 
given  intravenously  toxic  effects  may  be  produced  upon  animals. 
Burnam'"'  has  employed  finely  chopped-up  raw  luteum  of  the  sow  fed 
as  a  salad  or  the  dried  products,  and  states  that  the  latter  is  equally 
as  effective  provided  it  is  freshly  prepared.  He  states  that  patients 
vary  widely  in  their  susceptibility  to  the  dried  extract,  and  that  the 
actual  dose  can  be  determined  •  only  by  experimentation.  Some  pa- 
tients complain  of  the  taste  of  the  tablets,  and  occasionally  a  slight 
gastric  disturbance  is  produced.  With  these  exceptions,  Burnam'^  has 
noted  no  ill  effects,  even  from  enormous  doses,  while  the  beneficial 
results  have  been  marked.  In  those  patients  who  are  relieved,  the 
effect  is  generally  noted  in  a  few  daj's.  In  some  cases  the  administra- 
tion of  corpus  luteum  extract  appears  to  have  no  effect.  The  extract 
is  an  expensive  preparation,  and  for  this  reason  its  long-continued  ad- 
ministration is,  in  many  patients,  impracticable.  The  author's  ex- 
perience with  this  preparation  has  been  too  limited  to  draw  accurate 
conclusions  from.  Some  cases  appear  to  have  been  markedly  benefited, 
while  in  other  instances  little  or  no  result  has  been  apparent.     Whether 

'  Frankol:  Arcli.  f.  Gyii.,  1910,  vol.  xci,  p.  7.52. 

'Burnam,  C.  I"'.:   Jour.  .Vmer.  Med.  Assoc,  .Vugust  31,  1912,  p.  (i9S. 

'  Mayo,  C:  Jour.  Amcr.  Mod.  .\hsoc.,  1912,  vol.  lix,  No.  9,  p.  702. 

•Clark,  S.  M.  D.:  Ibid.,  p.  702.  » Litzenberg,  J.  C:  Ibid.,  p.  703. 

'■  Mainzpr:   Di'ut.  mod.  Woch.,  1890,  No.  12,  p.  188. 

'  de  Camboulas,  B.:   Le  Sue  Ovarien,  Paris,  1898.  «  Drevct:  Th&e de  Paris,  1907. 

»  Hill,  C.  A.:  Surg.,  Gyn.,  and  Ob.st.,  1910,  vol.  x,  p.  .W. 

i°G<xlart:   Thfee  de  Paris,  1908.  "  Villemin:   Thtse  dt- Lyoii.s. 

"  Ferroni,  E.:  .\nn.  di  o.stct.  Milano,  1907,  vol.  i,  p.  40."). 

"Lambert:  Compt.  rend.  Soo.  de  Biol.,  1907,  vol.  Ixii,  p.  18. 

"Burnam,  C.  I'".:  Jour.  Anier.  Med.  .Vssoc,  August  31,  1912,  p.  098. 

"Burnam,  C.  1'.:  Loc.  cil. 


3|J^  GONORRHEA    IN   WOMEN 

in  the  latter  cases  the  negative  results  have  been  due  to  improper 
dosage  or  faulty  extract  it  is  difficult  to  determine.  The  author  has 
never  seen  ill  effects  follow  its  use,  and  believes  that  when  given  by 
mouth  the  preparation  is  practically  harmless,  although  Krusen' 
states  that  in  one  instance  he  was  compelled  to  reduce  the  dose  because 
of  cardiac  palpitation  following  its  use.  The  preparation  employed 
should  be  a  carefully  made  desiccated  extract,  and  should  be  guarded 
against  exposure  to  extreme  heat  or  cold.  Fluidextracts,  whether 
aqueous  or  glycerinated,  have  not  proved  entirely  satisfactory. 
From  a  study  of  the  literature  on  this  subject  it  would  appear  that  the 
results  have  been  sufficiently  satisfactory  to  warrant  the  employment 
of  this  preparation  in  all  cases  exhibiting  distressing  symptoms  of  the 

artificial  menopause. 

\nother  therapeutic  indication  for  lutein  is  in  pregnant  women, 
on  whom  operations  upon  the  adnexa  have  been  performed,  and  mis- 
carriage is  feared.  This  is  especially  true  during  the  early  months  of 
pregnancy,  as  the  corpus  luteum  has  been  shown  experimentally  to 
have  a  definite  physiologic  action  upon  the  fecundated  ovum.  As  ■ 
a  general  rule,  the  extract  should  be  given  in  gradually  increasing 
doses. 

POST-OPERATIVE  CARE  OF  CASES  OF  PELVIC  INFLAMMATORY  DISEASE 
As  a  safeguard  against  peritonitis,  it  is  advisable  to  place  all  pa- 
tients in  the  Fowler  position  for  the  first  twenty-four  or  forty-eight 
hours  followihg  operation,  or  even  longer  if  distention  or  fever  is 
present.  A  great  advantage  of  the  Fowler  position  is  that  if  adhesions 
result,  they  occur  in  a  position  similar  to  that  assumed  by  the  patient 
while  upon  her  feet,  and  are  not,  therefore,  so  prone  to  cause  subse- 
quent distress.  If  the  bed  is  well  padded  and  adjusted  to  the  pro- 
portions of  the  individual  patient,  the  Fowler  position  does  not 
usually  cause  inconvenience.  If,  after  operation,  areas  of  infection 
still  persist  in  the  lower  genital  tract,  these  should  receive  appropriate 
treatment.  This  is  especially  important  in  cases  in  which  conservative 
operations  have  been  performed.  Failure  in  this  detail  and  reinfec- 
tion from  below  doubtless  account  for  a  definite  proportion  of  opera- 
tive failures. 

'  Knisen,  W.:  Aracr.  Jour.  Obst.,  October,  1912,  p.  524. 


CHAPTER  XIV 

UNUSUAL  MANIFESTATIONS  AND  REMOTE  COMPLICATIONS 
OF  PELVIC  INFLAMMATORY  DISEASE 

RUPTURE  OF  INFLAMMATORY   UTERINE   ADNEXA   INTO   THE   PERITONEAL 

CAVITY 

In  a  previous  chajiter  the  possibility  of  rupture  of  infiammatorj' 
tubal  collections  of  fluid  into  the  intestine,  bladder,  uterus,  peritoneal 
cavity,  or  even  through  the  abdominal  wall  was  mentioned.  Rupture 
or  perforation  of  an  adherent  pyosalpinx  into  the  rectum  is  not  in- 
frequent, and  into  the  bladder  or  upper  intestine  is  more  rare. 
Rupture  into  the  peritoneal  cavity  seldom  occurs,  and  is  the  form  of 
accident  described  in  the  following  pages. 

Rupture  may  occur  spontaneously,  or  may  be  the  result  of  direct 
violence,  as  from  a  kick  or  blow  on  the  vulva,  perineum,  or  lower  ab- 
domen. Mann'  and  others  report  cases  in  which  the  injury  is  supposed 
to  have  occurred  to  patients  during  their  transportation  to  a  hospital 
for  treatment  for  pelvic  inflammatory  disease.  At  least  one  reported 
case  was  caused  by  the  trauma  incident  to  a  curetage,  while  Fisher- 
reports  a  case  in  which  rupture  was  apparently  caused  by  the  apphca- 
tion  of  electricity  to  the  lower  abdomen.  The  Fallopian  tubes, 
situated  as  they  are  in  the  pelvis,  and  surrounded  laterally  by  the  bony 
prominences,  and  protected  from  below  by  the  strong  perineum  and 
the  intervening  structures,  and  from  above  by  the  thick  layer  of  in- 
testines and  the  abdominal  wall,  make  rupture  resulting  from  acci- 
dental traumatism  of  rare  occurrence.  Rupture  caused  by  ill-advised 
or  too  vigorous  bimanual  examination  has  occurred  in  a  number  of 
cases,  as  shown  by  the  reports  of  Legueu'  and  Martin.^  Violent 
coitus  may,  in  exceptional  cases,  result  in  the  bursting  of  a  pyosalpinx. 
Inflamed  tubal  collections  may  also  rupture  as  a  result  of  manipula- 
tions i)erf()rmed  for  the  purpo.se  of  inducing  abortion,  ("havassa"' 
recently  reported  a  case  of  this  kind,  and  Mary"  has  encountered  three 

'  Mann:  Aiiicr.  .(our.  Obst.,  1907,  vol.  Ivi,  p.  461. 
•'  Fi.shor,  .1.  M.:  Triin-s.  Phila.  Obst.  Soc,  Juno  1,  1011. 

"  Lctiiicu:  Compt.  rend.  Soc.  Ob.st.  do  (iyn.  ot  de  I';cd.  de  Paris,  1903,  vol.  v,  p.  83. 
'  Martin:  Rev.  prat,  d'ob.st.  ot  do  Pa^d.  do  Pari.s,  190G,  vol.  xix,  p.  2.30. 
'-  Chavassa,  M.:  Bull,  ct  do  la  Soc.  Anat.  do  Pari.s,  January  .5,  1910,  p.  79. 
"  Marv,  .\.:    "Sur  un  ca.s  do  rupture  de  pyosalpinx  pendant  I'uocouoliemont,"  Th^o 
do  Paris,  1908. 

319 


320  GONORRHEA    IN    WOMEN 

similar  cases  in  lying-in  women.  All  died.  Puerperal  infection  was 
the  diagnosis  made  in  these  cases.  Lejars'  states  that  the  flaring 
up  of  a  previously  chronic  process  may  lead  to  rupture.  Galliard  and 
Chaput-  have  reported  a  case  in  which  rupture  occurred  in  a  patient 
convalescing  from  typhoid  fever.  Latzko'  and  Cotte  and  Chalier* 
have  each  reported  a  case  of  ruptured  abscess  in  an  ovary.  Lejars=  has 
also  encountered  two  cases  in  which  the  tube  was  perforated  and  had 
become  gangrenous,  the  conditions  resembling  exactly  those  seen  in  a 
gangrenous  appendix.  The  peritonitis  following  these  cases  was  of  an 
unusually  severe  type.  In  Brickner's^  case  rupture  occurred  while 
the  patient  was  straining  at  stool.  A  number  of  cases  have  been  re- 
ported in  which  rupture  occurred  during  pregnancy  or  labor.  It 
is  probable  that  if  pelvic  inflammatory  disease  did  not  usually  cause 
sterility,  rupture  would  be  much  more  frequent,  as  the  uterus  slowly 
rising  out  of  the  pelvis,  to  which  an  inflammatory  tube  is  densely 
adherent,  causes  traction  on  the  tube,  a  drawing  out  and  tliinning  of 
this  structure,  which,  if  it  does  not  itself  finally  cause  rupture,  produces 
in  the  tube  a  condition  in  which  a  small  amount  of  trauma  may  pro- 
duce this  lesion.  Indeed,  Gonsolin^  states  that  under  such  circum- 
stances tubes  may  even  rupture  as  a  result  of  traction  in  which  both 
ends  are  patulous.     Labor  in  itself  may  cause  rupture. 

Spontaneous  rupture  is  rare.  Bonney,*  in  1909,  reported  a  case 
of  rupture  of  a  pyosalpinx,  and  carefully  reviewed  44  other 
authentic  cases  collected  from  various  sources.  This  writer'  states 
that  he  wrote ,  to  50  surgeons,  asking  for  reports  of  their  experi- 
ence with  cases  of  this  character.  Of  the  40  who  rephed,  but  14  had 
seen  the  condition.  Bovee,^"  in  1910,  collected  statistics  from  55 
cases,  and  submitted  the  history  of  an  additional  case  wliich  occurred 
in  his  own  practice.  In  the  majority  of  the  reported  cases  there  was  no 
assignable  cause  for  the  rupture.  In  the  minority  of  them  such  ex- 
citing causes  as  straining,  lifting,  the  muscular  efforts  incident  to 
labor,  traumatism  inflicted  during  coitus,  and  the  use  of  violent  purga- 
tives, seem  to  have  been  operative.  In  some  cases  rupture  evidently 
follows  a  fresh  puerperal  infection  superimposed  on  an  old  inflamma- 

'  Lcjars,  F.:  Semaine  M6dicale,  Paris,  April  12,  1911,  p.  169. 
2  Galliard  and  Chaput:  Semaine  M^dicale,  1909,  p.  538. 
5  Latzko:  Geb.  u.  Gyn.  Gesellschaft  in  Wien,  March  17,  1908. 
'  Cotte  and  Chalier:  Rev.  de  Gyn.  et  de  Chir.  Abdom.,  1907,  vol.  xi,  p.  579. 
^  Lejars,  F.:  Semaine  M^dieale,  Paris,  April  12,  1911,  p.  169. 
'  Brickner,  W.  M.:  Surg.,  Gyn.,  and  Obst.,  May,  1912,  p.  475. 

'Gonsolin:  These  de  Lyons;  also  quoted  by  Lamoreaux:  Les  Arch,  de  Gen.  Chir., 
January,  1910. 

»  Bonney,  C.  W.:  Surg.,  Gyn.,  and  Obst.,  1909,  vol.  ix,  p.  542. 

"  Bonney,  C.  W.:  Loc.  cit.  i"  Bovee;  Surg.,  Gyn.,  and  Obst.,  1910,  vol.  x,  p.  405. 


LTNUSUAL   MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         321 

tory  process.  Rupture  usualh'  takes  place  in  the  ampulla  of  the  tube, 
although  Alaryi  reports  a  case  in  which  the  rent  was  found  in  the 
isthmus.  In  the  cases  of  inflammatory  disease  of  the  uterine  adnexa 
in  wliich  rupture  occurs  the  primary  condition  is  almost  invariably  a 
pyosalpinx.  No  rule  can  be  formulated  as  to  the  size  of  the  pyosalpinx 
in  which  rupture  is  most  Ukely  to  occur — many  of  the  reported  cases 
have  been  small.  Naturally  those  specimens  in  which  the  walls  are 
thin  and  friable  are  more  prone  to  this  accident  than  are  those  in  which 
the  walls  are  thick  and  fibrous.  Adhesions  in  some  cases  probably 
play  an  important  part.  Recent  attacks  of  pelvic  peritonitis,  by 
augmenting  the  contents  of  the  tube  and  thereby  adding  to  the  iiitra- 
tubal  pressure,  and  by  inflammatory  changes  in  the  tubal  walls, 
increase  to  a  great  extent  the  likelihood  of  rupture. 

Symptoms. — The  sj'mptoms  arising  from  rupture  of  a  pj'osalpinx 
or  other  inflammatory  lesion  of  the  adnexa  naturally  vary  widely. 
If  the  rupture  takes  place  into  the  peritoneal  cavity,  grave  symptoms 
usually  result.  The  severity  of  the  symptoms  depends  largely  upon 
the  grade  of  the  infection,  and  perhaps  to  a  lesser  degree  upon  the  re- 
sistant powers  of  the  individual  patient.  It  is  quite  probable  that 
when  the  tubal  contents  have  become  sterile,  rupture  of  that  structure, 
with  escape  of  its  contents  into  the  peritoneal  cavity,  may  occur, 
with  little  or  no  ill  effects  to  the  patient;  indeed,  the  leakage  from  the 
end  of  a  tube  the  seat  of  a  salpingitis  is  but  a  mild  form  of  an  almost 
analogous  condition.  In  29  of  the  31  cases  analyzed  by  Bonney-  in 
which  rupture  occurred  into  the  peritoneal  cavity,  and  in  which  an 
accurate  history  of  the  attack  was  procurable,  the  onset  was  abrupt 
and  violent,  and  the  evolution  of  the  symptoms  rapid.  The  fact  that 
rupture  is  particularly  Ukely  to  occur  during  an  acute  exacerbation 
when  the  infecting  organisms  in  the  inflammatory  lesion  are  active, 
makes  the  prognosis  in  these  cases  much  less  favorable.  Sudden  sharp 
pain  in  the  lower  abdomen,  at  first  most  acute  over  the  seat  of  the 
lesion,  followed  by  more  or  less  marked  collapse  and  the  rajiid  develop- 
ment of  diffuse  peritonitis,  constituted  the  symptom-complex.  In 
Lamouroux's-'  series  the  onset  was  sudden  in  every  case,  and  was  usually 
accompanied  by  violent  pain  over  the  .scat  of  rupture,  which  soon  be- 
came general,  involving  the  lower  abdomen,  and  in  many  cases  the 
entire  peritoneal  cavity.  Nausea  and  vomiting  frequently  occurred. 
The  temperature  is  often  normal  or  subnormal  for  a  few  hours,  and  the 

'  Mary,  A.:  "Sur  un  caa  de  rupture  de  pyosalpinx  pendant  raeeouelieinciit,"  Tli&^e  de 
Pans,  1908. 

'  Bonney,  C.  W. :  Surg.,  Gyn.,  and  Obst.,  1909,  vol.  ix,  p.  542. 
'  Laniouroux,  H.  G.  A.:  Arch.  G(5n.  de  Chir.,  Paris,  September  2.5,  1912,  p.  1005. 
21 


322  GONORRHEA   IN  WOMEN 

pulse  rapid  and  weak;  pallor,  sweating,  and  other  symptoms  sug- 
gestive of  an  internal  hemorrhage  are  frequently  early  symptoms. 
The  temperature  soon  rises,  and  other  evidences  of  peritonitis  rapidly 
become  manifest.  The  disproportion  between  the  pulse-rate  and 
temperature  in  the  very  early  stage  is  a  suggestive  sign. 

In  those  cases  in  which  rupture  of  the  tube  has  taken  place  during 
labor  the  symptoms  have  usually  been  attributed  to  ordinary  puerperal 
infection.  Fabricius'^  case  is,  however,  an  exception,  and  prompt 
operation  resulted  in  the  saving  of  the  hfe  of  his  patient. 

Diagnosis. — If  the  surgeon  has  made  a  pelvic  examination  of  the 
case  before  rupture  has  taken  place,  and  is,  therefore,  familiar  with 
the  size  and  shape  of  the  diseased  adnexa,  a  comparison  between 
the  collapsed  tube  and  its  former  turgid  condition  will  be  of  the 
greatest  value  in  aiding  him  in  arriving  at  a  correct  diagnosis.  The 
condition  must  be  differentiated  from  the  acute  exacerbation  of  a 
chronic  pelvic  inflammatory  lesion;  from  torsion  or  rupture  of  an 
ovarian  neoplasm;  from  torsion  of  an  inflamed  tube  and  ovarj^; 
from  acute  appendicitis  with  perforation ;  and  from  ruptured  ectopic 
pregnancy  and  other  acute  conditions  of  the  lower  abdomen  that 
may  cause  peritonitis.  From  the  first  of  these  lesions  rupture  may 
be  distinguished  by  the  sharp,  localized  pain,  the  diffuse  character 
of  the  infection,  and  by  the  severity  of  the  symptoms.  The  cUnical 
picture  presented  by  the  rupture  or  acute  torsion  of  an  ovarian  cyst 
is  very  similar  to  that  of  rupture  of  a  pyosalpinx,  but  the  absence 
of  gonorrhea  in  the  lower  genital  tract,  the  history  of  the  case,  and, 
lastly,  the  pelvic  examination,  should  be  sufficient  to  enable  the 
surgeon  to  arrive  at  a  correct  diagnosis.  Torsion  of  an  inflamed 
uterine  appendage  is  so  rare  a  condition  that  it  need  hardly  be 
taken  into  consideration  in  the  ordinary  case.  In  this  condition, 
however,  the  symptoms  are  not  always  so  acute;  the  picture  of  diffuse 
peritonitis  is,  as  a  rule,  absent,  or  occurs  somewhat  later,  and  pelvic 
examination  will  reveal  an  enlarged,  tense  mass,  whereas  in  the  case  of 
rupture,  the  cyst-sac  is  collapsed  and  reduced  in  size.  The  two  condi- 
tions are,  however,  in  some  cases,  indistinguishable.  A  number  of 
recorded  cases  of  spontaneous  rupture  of  a  pyosalpinx  have  been  mis- 
taken for  appendicitis  or  a  ruptured  tubal  pregnancy,  and  the  correct 
diagnosis  has  been  made  only  after  the  abdomen  has  been  opened. 
Lejars-  strongly  emphasizes  the  necessity  for  bearing  in  mind  the 
possibility  of  rupture  of  an  inflamed  uterine  adnexa  when  confronted 
with  menacing  peritonitis  of  unknown  origin.     The  anamnesis  of  the 

'  Fabricius:  Wien.  klin.  Woch.,  1897,  vol.  x,  p.  10.56. 

2  Lejars,  F.:  Semaine  M6dicaje,  Paris,  April  12,  1911,  p.  169. 


UNUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         323 

case  often  shows  acute  flaring  up  of  an  infectious  process  just  before  a 
slight  contusion  occurs  that  induces  the  rupture.  However,  the  his- 
tory of  the  case  and  a  careful  pelvic  examination,  if  necessary,  made 
under  an  anesthetic,  should  in  most  instances  estabhsh  the  differential 
diagnosis  between  these  two  lesions.  From  ruptured  tubal  pregnancy 
torsion  may  be  distinguished  by  the  presence,  in  the  latter,  of  evidences 
of  pelvic  inflammatory  disease,  the  hyperpyrexia,  the  symptoms  of 
peritonitis,  and  the  absence,  in  many  cases,  of  the  signs  indicative  of 
internal  hemorrhage.  Fortunately,  the  treatment  of  all  the  conditions 
for  which  spontaneous  rupture  is  likely  to  be  mistaken  is  the  same, 
viz.,  operation.  In  Bonney's'  series  of  cases  suflficient  data  were  not 
obtainable  positivelj^  to  identify  the  variety  of  the  infecting  micro- 
organism in  the  majority  of  the  cases.  He  states,  however,  that  a  large 
proportion  of  them  were  of  gonorrheal  origin. 

In  a  study  of  the  literature  of  91  cases,  Brickner-  found  11  to  be 
clinically  of  gonorrheal  origin.  Many  reports  are  entirely  lacking  on 
this  point,  but  it  seems  probable  that  gonorrheal  pus-tubes  are  quite  as 
likely  to  rupture  as  are  those  due  to  other  varieties  of  infection.  The 
age  of  the  patients  varies  quite  widely,  rupture  naturally  occurring  most 
frequently  at  the  period  when  active  pelvic  peritonitis  is  most  frequent. 
Owing  to  the  insufficient  data  supplied  in  many  of  the  reports,  nothing 
definite  can  be  determined  regarding  the  duration  of  the  pyosalpinx 
and  the  number  of  acute  attacks  that  have  occurred  prior  to  the  rup- 
ture, although  recent  exacerbations  undoubtedly  exert  a  predisposing 
influence  on  this  condition. 

Menge  and  others  have  established  the  fact  that  in  a  definite  pro- 
portion of  cases  of  gonorrheal  pyosalpinges  the  tubal  contents  do  not 
contain  gonococci,  or  if  these  microorganisms  are  present,  they  possess 
only  a  limited  degree  of  virulence.  The  severe  symptoms  that  usually 
follow  the  rupture  of  an  inflammatory  tube  is  a  strong  argument  in 
favor  of  the  presence  of  a  mixed  infection  in  these  cases.  Another 
explanation  is  tliat  the  rupture  fre(iuently  occurs  during  an  exacerba- 
tion of  a  preexisting  pelvic  inflammatorj'  disease,  a  period  when  the 
microorganisms  present  in  the  tubal  contents  are  likely  to  be  especially 
virulent.  During  the  ciuicsceiit  ])eriod  infiannnatory  lesions  of  the 
tube  are  not  enhirging,  but  during  acute  attacks  more  pus  is  frequently 
being  formed  within  the  tube,  and,  as  a  consequence,  the  intratubal 
tension  is  increa.sed  and  rupture  at  this  period  is,  therefore,  more 
likely  to  take  place.  Subsequent  to  the  rupture  gonococci  have,  in 
many  cases,  been  demonstrated  in  the  peritoneal  exudate,  but  they 

'  Bonney,  C.  W.:  Surg.,  Gyn.,  and  Obst.,  1909,  vol.  ix,  p.  .542. 
'  Brickner,  \V.  M.:  tiurit.,  Gyn.,  iin<l  Olwt.,  May,  1911',  p.  IT.'). 


324  GONORRHEA   IN   WOMEN 

are  seldom  found  in  pure  culture,  and  are  usually  associated  with 
other  pathogenic  organisms.  Rupture  probably  occurs  almost  as  fre- 
quently on  one  side  as  on  the  other,  although  Brickner'  states  that 
in  53  cases  rupture  occurred  33  times  in  the  right  tube  and  23  times  in 
the  left.  The  fact  that  inflammatory  tubal  lesions  are  slightly  more 
frequent  on  the  right  than  on  the  left  must  be  taken  into  consideration. 
The  size  and  location  of  the  rent  also  vary,  but  usually  occur  in  the 
ampullae,  and  in  some  cases  the  rupture  merely  consists  in  the  tearing 
open  of  the  abdominal  ostium,  as  in  the  cases  recorded  by  Baisch,-  both 
of  which  were  of  puerperal  origin,  while  in  others  the  rupture  has  been 
found  in  the  tubal  wall.  As  in  many  cases  of  pelvic  peritonitis,  the 
opposite  tube  is  often  diseased. 

Prognosis. — The  prognosis  is  naturally  dependent  largely  upon  the 
variety  and  virulence  of  the  infecting  microorganism.  Bonney^  states 
that  of  the  45  cases  studied  by  him,  recovery  took  place  in  23  and  death 
occurred  in  the  remaining  22 — a  mortality  of  48.8  per  cent.;  while  in 
Bovee's^  series  of  56  cases  there  was  a  mortality  of  58  per  cent.,  32  having 
died  either  with  or  without  an  operation.  In  Lamouroux's^  series  of  27 
cases  9  patients  succumbed.  In  30  of  Bonney's"  cases  it  was  possible 
to  determine  the  time  that  elapsed  between  the  rupture  and  the  opera- 
tion. Of  20  patients  operated  upon  during  the  first  twelve  hours,  14 
recovered  and  6  died.  One  patient,  operated  upon  at  the  end  of  twenty- 
four  hours,  recovered.  Of  5  operated  upon  at  the  expiration  of  forty- 
eight  hours,  4  died  and  1  recovered.  Of  4  patients  operated  upon  be- 
tween the  fourth  and  the  tenth  day,  3  recovered  and  1  died.  An 
analysis  of  the  cases  in  which  operation  was  refused  or  contraindicated 
by  the  gravity  of  the  patient's  condition  shows  that  1  patient  died 
thirty-six  hours  after  the  presumable  time  of  rupture;  1,  forty-eight 
hours  afterward;  1,  seventy-two  hours  afterward;  2,  ninety-six  hours 
afterward;  and  2  at  the  end  of  two  weeks.  Of  the  remaining  8  pa- 
tients, 3  of  whom  recovered  and  5  of  whom  died,  nothing  could  be 
learned  either  with  reference  to  the  time  elapsing  between  the  per- 
formance of  the  operation  or  the  period  intervening  between  the  be- 
ginning of  the  attack  and  its  fatal  termination.  All  the  18  cases 
recorded  by  Bovee'  which  were  not  operated  upon  died.  The  length 
of  time  they  survived  after  rupture  varied  from  a  few  hours  to  three  and 

'  Brickner,  W.  M.:  Surg.,  Gyn.,  and  Obst.,  May,  1912,  p.  475. 

2 Baisch:    Miinch.  med.  Woch.,  September  19,  1911,  vol.  Iviii,  p.  1994., 

3  Bonney,  C.  W. :  Surg.,  Gyn.,  and  Obst.,  1909,  vol.  ix,  p.  542. 

«  Bov6e:  Surg.,  Gyn.,  and  Obst.,  1910,  vol.  x,  p.  405. 

'  Lamouroux,  H.  G.  A.:  Arch.  Gen.  de  Cliir.,  Paris,  September  25,  1912,  p.  1005. 

»  Bonney,  C.  W.:  Surg.,  Gyn.,  and  Obst.,  1909,  vol.  ix,  p.  542. 

'  Bov6e:  Surg.,  Gyn.,  and  Obst.,  1910,  vol.  x,  p.  405. 


UNUSrAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         325 

one-half  months.  Two  patients  admitted  to  the  hospital  on  the  four- 
teenth day  after  rupture  lived  respectively  four  and  twelve  days.  Of 
the  12  others  that  died  without  operation,  and  of  which  data  were 
obtainable,  the  average  number  of  hours  that  they  survived  was  fifty- 
nine.  Bovee^  and  Bonnej''  reiterate  the  statement  pre\iously  made  by 
Boldt'  that  there  is  not  a  single  case  on  record  in  which  recovery  took 
place  without  operative  intervention.  In  this  connection,  however, 
it  should  be  remembered  that  the  cases  in  which  recovery  would  be 
likely  to  occur  without  operation,  {.  e.,  those  in  which  the  tubal  con- 
tents were  sterile  or  in  which  the  microorganisms  were  attenuated,  and 
in  which,  as  a  consequence,  the  symptoms  would  be  of  a  milder  grade, 
are  the  very  ones  in  which  a  positive  diagnosis  of  rupture  would  be 
extremely  difficult  to  make.  It,  therefore,  seems  hkely  that  rupture 
ma}-,  in  some  instances,  take  place  and  be  mistaken  for  a  simple 
exacerbation  of  an  old  pelvic  lesion  and  not  cause  a  fatal  termination. 

Treatment. — .\11  cases  of  rupture  in  which  the  diagnosis  is  possible 
should  be  subjected  to  immediate  operation.  The  type  of  operation 
indicated  will  naturally  depend  upon  the  extent  and  variety  of  the 
lesions  encountered. 

The  following  is  Bovee's^  tablg  of  cases  of  ruptured  inflammatory 
adnexa,  to  which  has  been  added  a  synopsis  of  additional  cases  that 
occurred  since  his  excellent  report  was  pubhshed,  including  two 
occurring  in  the  Gynecologic  Department  of  the  University  Hos- 
pital, neither  of  which  has  previously  been  reported. 

Martin^  reports  briefly  2  cases  of  spontaneous  rupture  of  a  hydro- 
salpinx into  the  abdominal  cavity,  and  11  cases  in  which  rupture 
occurred  during  bimanual  examination.  Huras^  reports  6  cases  from 
Pozzi's  chnic.  A  further  contribution  to  the  subject  of  rupture  of 
suppurative  adnexal  lesions  may  be  found  in  Lamouroux's  paper  in 
the  These  de  Paris,  1912,  which  we  have  been  unable  to  obtain  at  the 
time  of  going  to  press. 

'  Bov(5c:  Loc.  cit. 

=  Bonney,  C.  W.:  Surg.,  Gyn.,  and  Obst.,  1909,  vol.  ix,  p.  542. 

»  Boldt:  Amer.  Jour.  Obst.,  1889,  vol.  xxii,  p.  2fy2. 

*  Bov(:'c:  Surg.,  Gyn.,  and  Ob.st..  1910,  vol.  x,  p.  40.5. 

'  Martin:  Kev.  prat,  d'obst.  ct  do  pindiat.,  Pari.s,  1906,  vol.  xix,  p.  2IJ0. 

'  Hura.s,  H. :  Mcnsuclles  d'obst.  ct  do  gyn.,  January,  1912. 


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UNUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         339 

TORSION  OF  INFLAMED  UTERINE  ADNEXA 
This  is  a  rare  condition,  and  a  search  through  the  Hterature  shows 
comparatively  few  recorded  cases,  when  the  frequency  of  inflammatory 
lesions  of  the  adnexa  is  borne  in  mind.  The  reason  for  this  can  easily 
be  understood  when  the  anatomy  of  the  tube  and  ovarj'  is  considered. 
The  two  requisites  for  torsion  of  these  structures  are  freedom  or  laxity 
of  adhesions  of  the  tube  or  ovary,  and  a  sufficiently  long-drawn-out 
condition  of  the  attachment  of  the  organs  so  as  to  form  a  pedicle. 
Until  the  last  few  years  torsion  of  the  inflamed  Fallopian  tube  has 
attracted  but  little  attention  in  this  country,  although  quite  a  few  cases 
have  been  reported  on  the  Continent,  especially  in  France,  where 
Hartmann  and  Reymond,^  Maillard,^  Cathehn,'  and  Simount''  have 
pubhshed  monographs  on  this  subject.  In  1899  Praeger^  reported 
two  cases,  and  was  able  to  collect  20  others  from  the  literature.  Three 
years  later  Cathelin's^  work  appeared,  in  which  he  reviewed  the  his- 
tories of  41  cases.  The  lines  are  not,  however,  sufficientlj-  tightly 
drawn  by  Cathelin,^  who,  for  example,  admits  a  case  of  parovarian 
cyst  to  his  list.  Hartmann  and  Reymond^  show  the  same  laxity,  as 
in  their  category  they  include  a  case  of  torsion  of  a  normal  Fallopian 
tube,  and  another  in  which  an  ovarian  neoplasm  was  present.  As 
torsion  of  ovarian  and  other  new-growths  of  the  adnexa  is  by  no  means 
unusual,  these  specimens  should  not  be  included  under  the  heading 
of  twists  of  inflamed  uterine  adnexa.  Praeger'  and  Bell'"  very  properly 
exclude  all  such  cases  from  their  reports.  Bell,"  in  1904,  adds  to  Cathe- 
lin's'-  list  13  new  cases,  including  one  of  his  own.  It  has  been  found  im- 
possible, owing  to  the  paucity  of  many  of  the  reports,  to  analyze  these 
cases  from  the  bacteriologic  standpoint.  In  the  Laboratory  of 
Gynecologic  Pathology  at  the  University  of  Pennsylvania  one  case 
of  torsion  occurred  among  925  inflammatory  tubal  lesions,  147  of 
which  were  either  hydrosalpinx  or  hematosalpinx.    The  history  of  this 

'  Hartmann,  H.,  and  Reyinond,  fi.:  Annales  de  Gyn.,  1898,  vol.  1,  p.  161. 

*  Maillard:  "De  la  torsion  des  salpingitis,"  Thfae  de  Paris,  1897-98. 

'  Cathelin,  V.:  "De  la  torsion  des  hydrosalpinx,"  Rev.  de  Chir.,  Paris,  1901,  vol. 
zxiii,  p.  2o:i. 

*  Simount,  G.  J.  P.:  "De  la  torsion  du  Pedicule  dans  Ics  Salpingitis,"  Bordeaux,  1908, 
p.  50. 

'  Praeger:  Arch.  f.  G>ti.,  1899,  vol.  Iviii,  p.  583. 

•Cathclin:  "De  la  torsion  des  hydrasalpinx,"  Rev.  de  Chir.,  Paris,  1901,  vol.  xxiii, 
p.  253. 

'Cathclin:  Loc.  cit.  '  Hartmann  and  llcymond:  Loc.  cti. 

'  Praeger:  Arch.  f.  Gyn.,  1899,  vol.  Iviii,  p.  583. 

'»  Bell,  R.  H.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  1904,  No.  5,  p.  514. 

"Bell,  R.  H.:  Ibid. 

"Cathelin:  "Dela  torsion  des  hydrosalpinx,"  Rcv.de  Chir.,  Paris,  1901,  vol.  xxiii, 
P.2.W.  i  i       • 


340  GONORRHEA   IN   WOMEN 

case  has  been  fully  recorded  by  Anspach/  together  with  a  synopsis 
of  87  other  cases  collected  from  the  literature. 

The  exact  etiology  of  torsion  of  inflamed  uterine  adnexa  is  difficult 
to  determine,  but  is  probably  largely  influenced  by  the  same  factors 
that  are  known  so  frequently  to  produce  similar  conditions  in  cases 
of  ovarian  neoplasms.  Among  the  causative  agents,  therefore,  are 
length  of  the  pedicle,  irregularity  in  the  shape  of  the  tumor,  flaccidity 
of  the  abdominal  walls,  alternate  filling  and  emptying  of  the  bladder 
and  rectum,  peristaltic  movements  of  the  intestines,  and  rapid  altera- 
tions in  intra-abdominal  pressure,  such  as  are  produced  by  pregnancy, 
labor,  paracentesis  abdominalis,  alternate  distention  and  evacuation  of 
the  intestines,  sudden,  unusual,  or  constrained  movements  of  the  body 
as  a  whole,  such  as  stooping,  turning  the  body  to  get  out  of  bed,  vomit- 
ing, trauma,  falls  or  jolts,  administration  of  an  enema,  gynecologic 
examinations,  pressure  of  the  abdomen  against  a  hard  object,  as  a 
wash-tub.  etc. 

Bell-  lays  particular  stress  upon  the  action  of  the  diaphragm  in  these 
cases.  Payr^  has  directed  attention  to  another  and  what  he  believes 
to  be  an  important  factor  in  the  production  of  torsion.  This  author 
believes  that  venous  stasis  in  the  pedicle,  especially  of  small,  freely 
movable  tumors,  may  cause  them  to  twist.  The  veins  in  many  such 
pedicles  are  extremely  tortuous, — much  more  so  than  the  arteries, — 
and  as  a  result  of  intense  congestion,  impart  a  spiral  motion  to  the 
tumor;  as  twists  occur  the  stasis  becomes  increased  and  a  sort  of 
vicious  circle  'is  formed.  Payr's  article  contains  a  number  of  illus- 
trations. The  ovarian  veins  are  normally  unusually  tortuous,  so  that 
the  foregoing  theory  is  particularly  applicable  to  torsion  of  inflam- 
matory tumors  of  the  adnexa.  Naturally,  on  account  of  adhesions 
and  the  shortness  of  the  pedicle,  twists  occurring  in  appendages  the 
seat  of  inflammatory  disease  are  of  rare  occurrence. 

The  ovary  itself,  owing  to  its  situation  and  lack  of  pedicle,  is  rarely 
primarily  subject  to  this  condition,  although  not  infrequently  it  par- 
ticipates more  or  less  when  the  tube  is  twisted.  Tubes  the  seat  of 
pus  collections  seldom  undergo  torsion.  A  pyosalpinx  is,  as  a  rule, 
densely  adherent  throughout  its  entirety  to  the  adjacent  structures, 
and,  owing  to  its  generally  smaller  size  compared  to  a  hydrosalpinx, 
is  much  less  likely  to  undergo  twists  than  is  a  tube  affected  with  the 
latter  condition.     In  Anspach's*  series  of  88  cases  of  tubal  torsion 

lAnspach,  B.  M.:  Amer.  Jour.  Obst.,  October,  1912,  p.  553. 
-  Bell,  R.  H.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  1904,  No.  5,  p.  514. 
2  Payr:  Arch.  f.  klin.  Chir.,  1902,  vol.  Ixviii,  p.  601;  also  Deut.  Zeitschr.  f.  Chlrurg., 
1906,  vol.  Ixxxv,  p.  392. 

■'  Anspach:  Trans.  Amer.  Gyn.  Soc,  1912. 


Fio.  35. — Acute  Pchulext  Salpingitis. 
The  tube  is  pipe  shaped,  and  more  closely  resembles  a  serous  than  a  purulent  arcuinulatiun.  Tlic  inner  half 
of  the  tube  is  but  tittle  enlarged,  and  the  mesosalpinx  is  thin.  The  ampulla  is  dilated.  The  walls  are  thin, 
and  the  surface  shows  only  a  few  slight  adhesions.  The  abdominal  ostium  is  contracted,  and  the  fimbrice  arc 
Btili  to  be  seen.  On  section,  the  lumen  was  found  to  be  necrotic  and  filled  with  pus.  This  is  (he  type  of  puru- 
lent tubal  accumulation  in  which  torsion  may  occur. 


UNUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         341 

there  were  12  pyosalpinges,  not  all  of  which  were,  however, 
primaril}^  pus-tubes ;  of  these,  3  were  known  to  be  tubercular  and 
3  more  were  possibly  the  result  of  this  tj^je  of  infection.  This  is 
only  what  would  be  expected,  as  tuberculosis  tends  to  produce  a 
retort-shaped  tubal  enlargement  more  often  than  does  the  gonococcus 
or  the  other  j^yogenic  microorganisms.  Also  in  tuberculosis  the  ad- 
hesions are  often  less  marked  than  in  the  other  forms  of  infection. 

In  Cathelin's'  list  of  41  observations  there  were  only  6  pyosalpinges, 
and  he  gives  reasons  for  thinking  that  even  these  were  not  primarily 
cases  of  purulent  salpingitis,  but  were,  rather,  originally  hydrosalpinges 
wth  subsequent  intratubal  suppuration.  A  hydrosalpinx,  on  the  other 
hand,  because  of  the  frequent  retort-like  shape  the  tube  assumes, 
which  tends  to  elongate  the  isthmus  of  the  tube  and  the  mesosalpinx, 
and  thus  forms  a  pedicle,  is  much  more  prone  to  develop  this  complica- 
tion. The  adhesions  in  hydrosalpinges  are  generally  less  numerous, 
and  cases  in  which  the  ampulla  of  the  tube  is  entirelj^  free  are  not 
unusual.  Without  exception,  all  the  recorded  cases  that  are  accom- 
panied by  a  detailed  description  of  the  shape  of  the  tube  show  that  the 
chief  enlargement  is  situated  in  the  ampulla,  and  this  is  usually  con- 
nected with  the  cornua  of  the  uterus  by  a  fairh^  long,  gracile  pedicle, 
consisting  of  the  inner  portion  of  the  tube  and  the  drawn-out  and  more 
or  less  thinned  mesosalpinx.  As  previously  pointed  out,  there  can  be 
no  doubt  that  many  of  the  cases  reported  as  torsion  of  a  pyosalpinx 
are  in  reality  cases  of  hydrosalpinx  in  which  pus  or  purulent  material 
has  formed  as  a  result  of  the  interference  with  the  blood-supply  caused 
by  the  twisting.  The  large  proportion  of  cases  of  hydrohematosal- 
pinges  and  hematosali)inges  can  also  be  accounted  for  in  the  same 
manner,  just  as  hemorrhage  occurs  in  an  ovarian  cyst  when  its  pedicle 
is  twisted. 

Direction  of  Rotation.  -  The  metliods  of  describing  tlii.s  condition 
are,  as  a  rule,  confusing.  The  best  plan  is  that  ad<jpte(l  by  the  French 
writers,  who  state  that  the  rotation  is  in  the  direction  in  which  the 
hands  of  a  watch  travel,  or  is  in  the  opposite  direction.  It  is  under- 
stood that  the  back  of  the  watch  is  supposed  to  be  toward  the  uterus 
and  the  face  directed  outward  toward  the  tumor  or  the  crest  of  the 
ilium.  Cathelin^  gives  the  analysis  of  12  cases  in  which  it  was  jios- 
sible  accurately  to  determine  the  direction  of  the  torsion. 

'  C'athclin:  "  Oc  lii  torsion  tics  liyilro.siilpiiix,"  Kev.  dc  Cliir.,  ]';iris,  I'.IOl,  vol.  xxiii,  ]). 
253. 

^Cnl)i(lin:  '■  I)c  la  torsion  (Ics  hyilro>alpinx,"  Kcv.  de  Chir.,  I'liris,  IttOl,  vol.  xxiii, 
p.  2.53. 


342  GONORRHEA    IN    WOMEN 

Right  Side: 

In  the  direction  of  the  hands  of  a  watch 2  cases 

In  the  reverse  direction  of  the  hands  of  a  watch 5     " 

Left  Side: 

In  the  direction  of  the  hands  of  a  watch 2  cases 

In  the  reverse  direction  of  the  hands  of  a  watch 3     " 

It  can  thus  be  seen  that  there  appears  to  be  no  rule  in  this  respect. 
The  following  table  shows  the  ages  at  which  torsion  occurred  in  the 
46  cases  in  which  it  was  possible  to  determine  this  point : 

1  case  was  under  twenty  years  of  age. 
16  cases  were  between  twenty  and  thirty  years  of  age. 
20     "        "  "        tliirty  and  forty  years  of  age. 

8      "         "  "        forty  and  fifty  years  of  age. 

1  case  was  between  fifty  and  sixty  years  of  age. 

Pregnancy  does  not  seem  to  be  a  predisposing  factor  of  much 
moment  so  far  as  torsion  is  concerned.  Bell^  states  that  of  38  cases, 
10  were  nulUparous,  and  15  had  only  had  one  labor;  while  in  Anspach's^ 
series  38  out  of  65  cases  in  which  the  condition  was  noted  had  one  or 
more  children,  a  not  unusual  proportion. 

At  the  same  time,  several  cases  have  been  directly  associated  with 
pregnancy  or  the  puerperium.  Numerous  pregnancies  would  naturally 
weaken  the  abdominal  walls  and  thus  favor  torsion.  On  the  other 
hand,  inflammatory  disease  of  the  adnexa  usuallj^  produces  sterility, 
and  unless  the  infection  occurred  as  a  result  of  childbirth,  hydrosalpinx 
and  other  inflammatory  tumors  are  generally  absent  during  the  puer- 
perium. 

Torsion  of  the  inflamed  appendages,  like  a  similar  condition  oc- 
curring in  the  pedicle  of  ovarian  neoplasms,  may  be  either  of  sudden 
onset,  the  twist  interfering  with  the  blood-supply  of  the  tumor  to  such 
an  extent  that  gangrene  or  other  severe  circulatory  disturbances  are 
produced,  or  the  rotation  may  be  slow  and  perhaps  repeated  a  number 
of  times,  producing  a  more  chronic  lesion.  No  sharp  line  can  be  drawn 
between  these  two  varieties,  as  various  intervening  degrees  of  torsion 
may  be  encountered.  The  acute  type  is  the  variety  that  has  been 
most  frequently  recorded. 

In  the  cases  recorded  by  Ries,^  Rouffart,"*  Guicciardi,^  Kauff'mann,' 
and  Kadigrobow,^  the  torsion  had  been  so  complete  as  to  produce  an 

1  Bell,  R.  H.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  1904,  No.  5,  p.  514. 
'  Anspach:  Trans.  Amer.  Gyn.  Soc,  1912. 
»  Ries:  Amer.  Gyn.  and  Obst.  Jour.,  April,  1900,  p.  325. 

'  Rouffart:  Jour.  Med.  de  Bruxelles,  1900,  No.  12,  ref.  Zent.  f.  Gvn.,  1900,  vol.  xxxvii, 
p.  975. 

'  Guicciardi,  G.:  Ginecologia,  1905,  vol.  ii,  p.  110,  1  pi. 

»  Kauffmann:  Zent.  f.  Gyn.,  1903,  vol.  -xlix,  p.  139. 

'  Kadigrobow,  B,  A.:   Abst.  Zent.  f.  Gyn.,  1907,  No.  32,  p.  991. 


UNUSUAL   MANIFESTATIONS   AND    REMOTE    COMPLICATIONS         343 

amputation  of  the  tube,  and  in  Waldo's^  case  the  tube  was  almost 
twisted  off.  Tubes  the  seat  of  the  torsion  usually  present  a  dark 
reddish  or  blackish  appearance,  and  show  the  same  circulatory  changes 
that  are  observed  in  ovarian  neoplasms  under  similar  circumstances. 
As  before  mentioned,  the  tubes  that  are  the  seat  of  torsion  are  usually 
of  the  retort-shaped  variety,  the  outer  end  being  enlarged,  in  the  inner 
portion  forming  the  more  or  less  slender  pedicle.  As  a  result,  the 
twists  are  almost  always  formed  in  the  proximal  half  of  the  tube. 

Symptoms. — These  naturally  depend  upon  the  aeuteness  of  the 
condition.  A  history  pointing  toward  a  previously  existing  pelvic 
inflammatory  lesion  can  usually  be  elicited,  whereas  not  infrequently 
prior  attacks  of  torsion  of  a  mild  degree  will  have  been  present.  In 
some  cases  the  acute  attack  seems  to  have  been  produced  by  a  sudden 
strain,  as  in  Ross'-  case,  in  which  the  twist  was  probably  caused  by  the 
patient  cranking  a  motor  car.  In  other  cases  a  fall,  violent  exertion, 
or  straining  at  stool  seems  to  have  been  the  causative  factor,  while  in 
still  other  instances  the  condition  has  occurred  without  assignable  cause. 

In  some  cases  the  torsion  is  gradual  and  the  onset  of  symptoms  only 
moderately  acute,  while  in  others  the  torsion  seems  almost  completely 
to  shut  off  the  blood-supph^  and  as  a  result  the  symptoms  are  severe. 
In  some  cases  it  seems  likelj'  that  a  number  of  attacks  caused  by  a 
gradual  torsion  have  occurred.  In  63  per  cent,  of  the  recorded  cases 
the  patients  have  been  kept  under  observation  for  a  time  before  opera- 
tion, showing  that  in  a  definite  proportion  the  symptoms  at  the  onset 
were  not  verj-  alarming.  ■Many  of  these  cases  were  at  first  mistaken 
for  an  ordinary  acute  exacerbation  of  a  pelvic  inflammatory  disease. 
In  17  of  Cathehn's^  cases  in  which  menstruation  is  mentioned,  in 
only  4  was  there  any  irregularity.  The  seizure  is  almost  invariably 
ushered  in  by  an  attack  of  severe,  sharp  pain  in  the  lower  abdomen, 
over  the  seat  of  the  lesion.  This  is  accompanied  by  more  or  less 
marked  symptoms  of  shock  and  collapse,  which  are  followed  shortly 
by  the  evidence  of  acute  pelveoperitonitis,  which  not  infrequently  be- 
comes general.  Nausea,  vomiting,  hyperpyrexia,  and  elevation  of  the 
pulse-rate  are  jirominent  symj)toms.  The  aljdomen  Ijecomes  distended 
and  tender,  the  recti  muscles  rigid,  and  constipation  is  the  rule,  and  in 
some  cases  is  absolute.  Retention  of  urine  or  irritability  of  (he  bladder 
and  fre(iuency  of  micturition  are  often  observed.  Examination  reveals 
the  presence  of  a  more  or  less  fluctuating  tumor,  which  seldom  rises 

'  Waldo:  Amcr.  .Jour.  Obst.,  August,  1901,  p.  17'.». 

'  Uoss:  Ainer.  Jour.  Obst.,  1900,  vol.  liv,  p.  033;  also  Trans.  Amcr.  Assoc.  Obst.  antl 
C.yn.,  190G,  New  York,  1907. 

'Cathelin:  "De  la  torsion  des  hydrosalpinx,"  Rcv.de  Chir.,  Paris,  I'.tOI,  vol.  xxiii,  p. 
2.53. 


344  GONORRHEA    IN   WOMEN 

above  the  umbilicus  and  is  of  pelvic  origin.  This  may  be  situated 
either  in  the  pelvis  or  in  the  abdomen,  but  is  usually  low  down.  In 
cases  in  which  a  pelvic  examination  has  been  made  prior  to  the  attack, 
the  change  in  the  shape  and  consistence  of  the  tumor  will  be  a  great 
aid  in  clearing  up  the  diagnosis.  Subsequent  to  the  torsion  the  tube 
will  be  found  to  be  somewhat  enlarged,  extremely  tender,  and  often 
firmer  than  formerly,  and  to  possess  a  rather  more  circumscribed  range 
of  mobility.  The  enlargement  is  sometimes  very  marked.  Bimanual 
examination  may  show  that  the  position  of  the  uterus  is  altered. 
The  presence  of  inflammatory  disease  of  the  opposite  side  is  suggestive, 
as  more  than  one-half  of  the  recorded  cases  show  this  to  be  present. 
It  may  also  be  possible  to  demonstrate  the  pedicle  of  the  tumor  and 
its  association  with  the  uterus.  These  patients  usually  display  such 
tenderness  on  examination,  and  the  abdomen  is  often  so  markedly 
distended,  that  a  general  anesthetic  is  necessary  before  a  satisfactory 
examination  can  be  made. 

Diagnosis. — BelP  and  Anspach-  state  that  an  absolutely  correct 
diagnosis  of  this  condition  has  never  been  made.  Torsion  is  somewhat 
more  frequent  on  the  right  than  on  the  left  side.  In  the  88  cases 
analyzed  by  Anspach,^  44  occurred  on  the  right,  33  on  the  left,  side, 
7  were  bilateral,  and  the  location  of  the  remainder  was  not  stated. 
The  less  space  on  the  left  side  of  the  pelvis,  owing  to  the  presence  of  the 
sigmoid  flexure,  the  more  active  peristalsis  of  the  small  intestines, 
and  the  cecum  on  the  right,  and  perhaps  the  greater  frequency  of  in- 
fection of  the  right  tube,  owing  to  the  close  anatomic  relationship  to 
the  vermiform  appendix,  may  perhaps  account  for  this  fact.  As  a 
result  of  torsion,  rupture  may  occur,  as  in  the  cases  of  Lejars'*  and 
Caput. ^ 

The  symptoms  and  the  abdominal  and  pelvic  examination  so  closely 
simulate  torsion  of  the  pedicle  of  an  ovarian  tumor,  and  the  latter 
condition  is  relatively  so  frequent,  that  torsion  of  inflamed  appendages 
is  usually  mistaken  for  an  ovarian  neoplasm.  Ovarian  tumors  are 
often  round,  and  this  point  should  be  considered,  as  well  as  the  fact 
that  the  latter  are  not,  as  a  rule,  associated  with  the  other  symptoms 
of  pelvic  inflammatory  disease.  Small  ovarian  tumors  are  the  most 
difficult  to  differentiate.  Torsion  may  also  be  mistaken  for  appendi- 
citis and  intestinal,  renal,  or  ureteral  colic.  These  conditions  should, 
however,  readily  be  excluded  if  a  careful  study  of  the  case  and  a 
thorough  pelvic  examination  are  made.     Certain  cases  of  ruptured 

'  Bell,  R.  H.:  Jour.  Obst.  and  Gyn.  of  Brit.  Emp.,  1904,  No.  5,  p.  514. 
*  Anspach:  Trans.  Amer.  Gyn.  Soc,  1912.       ^Anspach:  Trans.  Amer.  Gyn.  Soc,  1912. 
'  Lejars,  F. :  Compt.  rend.  Soc.  d'obstet.,  de  gynec.  et  de  psediat.  de  Paris,  1909,  vol. 
xi,  p.  342;  also  Semaine  m6d.,  Paris,  1910,  vol.  xxx,  p.  325. 
'  Caput:   Rev.  de  Gyn.,  1906,  vol.  x,  p.  963. 


UNUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         345 

ectopic  pregnancy  may  also  closely  simulate  torsion,  but  the  histoiy, 
the  absence  of  other  evidences  of  inflammatory  disease,  and  the  fact 
that  in  the  latter  the  symptoms  of  hemorrhage  are  absent,  should  aid 
the  operator  in  making  his  diagnosis.  Torsion  of  gravid  tubes  has 
been  recorded.  Fortunately,  the  correct  diagnosis  is,  as  a  rule,  of 
no  great  practical  importance,  as  operative  intervention  is  required 
in  all  the  conditions  for  which  torsion  is  likely  to  be  mistaken. 

In  the  87  cases  summarized  by  Anspach,^  25  were  diagnosed  as 
ovarian  cysts  with  twisted  pedicle,  in  20  as  pelvic  inflammatory 
disease,  in  2  as  gynatresia  with  distention,  in  1  as  acute  strangulation 
of  the  intestine,  and  in  30  no  clinical  diagnosis  was  made.  One 
remarkable  case  presented  no  subjective  symptoms  whatever,  the 
tumor  being  discovered  accidentally. 

Treatment. — Briefly  summarized,  it  may  be  stated  that  inmiediate 
operation  is  required  in  all  cases  of  torsion,  and  the  earlier  it  is  per- 
formed, the  more  favorable  will  be  the  prognosis.  The  type  of  opera- 
tion selected  will  naturally  vary  according  to  the  nature  and  extent 
of  the  pathologic  condition  encountered.  If  the  lesion  is  confined  to 
one  side,  the  opposite  appendages  being  normal,  a  simple  salpingo- 
oophorectomy,  with  excision  of  the  intramural  portion  of  the  tube  and 
retention  of  the  uterus  in  a  good  po.sition,  will  usually  be  all  that  is 
necessar}\  On  the  other  hand,  if  the  lesions  are  extensive,  a  more 
radical  operation  will  be  rccjuired. 

The  following  is  a  summary  of  recorded  cases,  manj'  of  which 
have  been  taken  from  Anspach's-  excellent  paper  on  this  subject. 
As  has  previously  been  mentioned,  the  etiology  of  many  of  these  cases 
is  in  doubt.  None,  however,  is  included  which  is  known  to  be  caused 
by  microorganisms  other  than  the  gonococcus. 

AWerlin  (Lyon  Med.,  1011,  vol.  cxvii,  p.  29). — Hydrosalpinx,  twisted  on  uterine  pedicle, 
ecchymotic  in  eolor  and  indicative  of  necrosis. 

AWerlin  fLyon  M^-tl.,  190.5,  vol.  cv,  p.  1040). — Case  1. — .Vkc,  eiRhteen.  Diagnosis  before 
oper.ition:  Bilateral  ovarian  cyst.  Diagnosis  after  operation;  Hilateral  hydrosalpinx. 
Uiglit,  twisted.  Opposite  side,  hydrosalpinx  and  ovarian  cyst.  Repeated  attacks  of 
ovarian  pain. 
Cage  2.  -.\ge,  sixteen.  Hydrosalpinx.  Twisted  three  times,  with  repeated  attacks  and 
abdominal  pain  becominK  progressively  worse.  Diagnosis  before  operation:  Ovarian 
cy.st  with  twisl('<l  i)edicle. 

Amann  (.Monal.  f.  Geb,  u.  Gyn.,  vol.  xv.  No.  2). — .Age,  thirty-three.  Il-para.  Sudden 
attacks  of  .severe  pain.  Previous  good  health.  Median  abdominal  tumor  three  inches 
below  umbilicus.  Operation  ten  days  after  attack.  Diagnosis  before  operation: 
Ovarian  cyst,  torsion.  Diagnosis  at  operation:  Highl  hydro.salpinx,  twisted  2'  ■•  limes. 
Tube,  20  cm.  long  and  (1  cm.  in  diameter.  Number  of  adhesions  to  intestine  and 
mesentery. 

/lr//,iir  rDeut.  Zeit.  f.  Chir.,  vol.  xlviii,  Nos.  2  and  .'?,  p.  19S).— .\ge,  twenty-one.  Diagnosis 
before  operation:   Appendicitis  or  right  adnexal  di.sea.se.     Seven  days  before  operation 

'  .\nspach:   Jjoc.  cil. 

■•  .\nspach.  B.  M.:   Amer.  .Jour.  ( )l.sl ,,  October.  1912,  vol.  Ixvi,  p.  .'),■■):{. 


346  GONORRHEA   IN   WOMEN 

acute  symptoms  began.  The  tumor  was  present  in  the  right  iliac  fossa,  which  was 
easily  outlined.  At  operation  hydrosalpinx  was  found  in  the  right  side,  the  size  of  an 
ostrich  egg,  the  pedicle  of  which  was  twisted. 

Aulhorn  (Zent.  f.  Gynak.,  1910,  No.  16,  p.  538). — Age,  nineteen.  Three  months  pregnant. 
Pain  for  some  weeks.  Acute  exacerbation  two  days  before  admission.  Diagnosis 
before  operation:  Pregnancy  and  pyosalpinx.  Diagnosis  after  operation:  Right 
hematosalpinx,  twisted  180  degrees;  tumor  9  cm.  long,  dark-blue  color;  ovary  in- 
volved; uterus  gravid. 

Baldwin  (Amer.  Jour.  Obst.,  1906,  vol.  liv,  p.  654). — Age,  forty-three.  No  children;  one 
miscarriage.  In  attempting  to  sit  down,  missed  chair  and  fell  heavily;  three  hours 
later,  severe  pain.  Diagnosis  before  operation:  Acute  appendicitis.  Emergency 
operation.  Ovaries  not  disturbed  and  not  affected.  The  tubes  contained  serum  and 
blood.     Diagnosis:  Bilateral  hydrosalpinx,  right  tube  twisted  and  gangrenous. 

Baiidron  (Compt.  Rend.  Soc.  d'obst.  de  Gyn,  et  de  Pied.,  1900,  vol.  ii,  p.  90). — Age,  thirty- 
two.  One  miscarriage  at  nineteen  years.  Diagnosis  before  operation:  Tubal  preg- 
nancy (ruptured).  Diagnosis  after  operation:  Hydrosalpinx,  twisted.  Side,  right. 
Size,  orange.  Location,  tumor  adherent  to  parietal  peritoneum  of  pelvis.  Form, 
irregular,  nodular,  ecchymotic.     Pedicle,  size  of  little  finger.     Torsion. 

Bell  (Joiu-.  Obst.  and  Gyn.  of  Brit.  Emp.,  1904,  No.  5,  p.  514). — Age,  forty-five.  Married 
at  nineteen;  child  in  eighteen  months;  no  other  pregnancies.  Family  history  tu- 
berculous. Attack  of  severe  pain  in  1899,  with  faintness  and  vomiting;  lasted  two 
hours;  no  doctor.  In  1901,  another.  Present  attack  sharpest.  Abdominal  tumor 
found.  Diagnosis  before  operation:  Ovarian  cyst,  twisted  pedicle.  Diagnosis:  Hy- 
drosalpinx, twisted  1  ^/^,  reversely  to  hands  of  watch.  Twisted  tube  almost  black  in 
color.     Left  side  also  inflamed. 

Bland-Sutton  (Surg.  Dis.  of  the  Ovary  and  Fallopian  Tubes,  London,  1891). — Case  of 
Dr.  H.  Morris.  Symptoms  not  acute;  ovary  not  involved.  A  hydrosalpinx  was 
twisted  3J-2  times.  Numerous  dense  adhesions  and  partial  amputation  and  parasitic 
growth  resulting  from  impairment  of  the  normal  blood-supply. 

Boursier  (Jour,  de  m^d.  de  Bordeaux,  1901,  No.  30,  p.  512). — Age,  thirty-four.  Nullipara. 
Diagnosis  before  operation:  Endometritis;  adherent  retroflexion;  salpingo-oophoritis 
(right).  Diagnosis  after  operation :  Right  hydrosalpinx,  twisted  2^2  tinies.  Opposite 
side,  follicular  cysts  in  ovary,  congested  tube.  In  1899  severe  pains  right  iliac  fossa, 
especially  if  fatigued,  increased  at  menstrual  periods;  gradually  grew  worse,  coming  on 
in  attacks  when  fatigued.  During  month  before  admission  (1901)  pains  suddenly  in- 
creased in  violence  \vithout  apparent  cause;  went  to  bed;  sUght  fever  and  painful 
micturition.  Objective  signs:  Abdomen  not  distended.  Behind  and  to  the  right  of 
uterus  a  mass  not  very  hard,  difficult  to  outline;  tender.  Operation:  Right  salpingo- 
oophorectomy.     Result,  cure. 

Brewis,  N.  T.  (Edinburgh  Med.  Jour.,  1910,  N.  S.  4,  vol.  i,  p.  448). — Showed  an  example  of 
torsion  of  the  tube  before  the  Edinburgh  Obstetrical  Society.  There  was  no  descrip- 
tion of  any  kind. 

Burrage  (Bost.  Med.  and  Surg.  Jour.,  1906,  vol.  chv.  No.  11,  p.  295). — Age,  twenty-six. 
Married  two  years;  nullipara.  Treated  for  dysmenorrhea  December,  1898.  Dudley's 
operation.  Pelvis  negative,  except  prolapse  of  right  ovary.  Acute  attack  November, 
1899.  Diagnosis  before  operation:  Pelvic  abscess.  Diagnosis  after  operation: 
Hydrosalpinx  twisted.  Right  salpingectomy;  resection  of  both  ovaries.  Left  tube 
normal.  Both  ovaries  riddled  with  cysts.  Twisted  right  hydrosalpinx  adherent  to 
bladder  and  surrounding  structures.  Color,  dark,  reddish-brown.  Contents,  blood- 
clot,  no  villi. 

Cathelin-  {Rev.  de  Chirurg.,  1901,  vol.  xxiii,  p.  253).^Age,  twenty-six.  One  miscarriage 
of  five  months  seven  years  previously.  Diagnosis  before  operation:  Massive  sal- 
pingitis (left);  sUght  adnexitis  (right).  Diagnosis  after  operation :  Left  hydrosalpinx, 
twisted  2J/2  times.  Form,  ovoid;  color,  blackish;  contents,  200  grams  blood;  no 
clots;  adhesions  present.  Ovary  not  twisted.  Adnexa  of  opposite  side  normal. 
Objective  signs:  Tender  mass  in  posterior  culdesac  (left).  Subjective  conditions: 
Very  active  pains  in  left  lower  abdomen  three  years  before  operation,  without  other 
symptoms;  for  three  years  uterine  discomfort.  Evening  before  operation,  violent 
pains  on  rising  from  a  chair.  Operation:  Unilateral  salpingo-oophoreetomy.  Result, 
cure. 

Calhdin  (Bull,  et  mem^  de  la  Soc.  de  Anat.  de  Paris,  1900,  6  S.,  T.  ii,  vol.  Ixxv,  p.  673).— Age, 
forty;    Il-para.     Sudden  seizure;   repetition  in  .sixteen  days;   mobile  tumor  on  right, 


UNUSUAL   MANIFESTATIONS   AND    REMOTE    COMPLICATIONS         347 

by  pelvic  examination.  Left  hydrosalpinx,  twisted  1J4  times,  direction  of  hands  of 
watch.  Ovary  not  involved.  Blackish  tumor.  Right  hydrosalpinx  adherent  in 
Douglas'  pouch. 

Chido  (Bull,  et  mem.  de  la  Soc.  de  Anat.  de  Paris,  1900,  6  S.,  vol.  ii,  p.  41).— Age,  tiiirty. 
XulHpara.  Diagnosis  before  operation:  Bilateral  salpingitis.  Acute  exacerbation  on 
right  side.  Objective  signs:  Abdomen  distended  on  right  side,  rising  nearly  to  umbiUcus. 
On  left  side,  tumor  size  of  mandarin  orange,  fluctuant.  At  operation:  Right  hydro- 
salpinx, twisted  3  times  and  contained  300  grams  dark,  bloody  fluid  and  a  small  hemor- 
rhagic cyst  of  the  ovary.     Operation:  Bilateral  salpingo-oophoreetomy.     Result,  cured. 

Dclbel,  P.  (Bull,  et  mem.  de  la  Soc.  de  Anat.  de  Paris,  1892,  p.  300). — Age,  thirty-nine. 
Diagnosis  before  operation:  Intestinal  strangulation  from  bands  of  volvulus  of  sigmoid. 
Operation  within  thirty-six  hours.  Diagnosis  after  operation:  Left  hydrosalpinx, 
3  twists.  Right  hydrosalpinx.  Left  ovary  not  twdsted.  Objective  signs:  Palpation 
very  painful.  Suljjective  conditions:  Very  sudden  and  severe  pain;  fainting.  Patient 
fell  while  walking  on  street.  Continued  vomiting,  not  fecal.  Pulse  full,  rapid; 
temperature,  normal.     Operation:     Bilateral  salpingo-oophoreetomy.     Result,  cure. 

Ddore  and  Alamartin  (Lyon  M6d.,  1909,  No.  9,  p.  416). — Age,  thirty-eight.  No  general 
history.  No  signs  of  inflammation.  Diagnosis:  Bilateral  hydrosalpinx,  right  twisted 
2  or  3"  times,  containing  one-half  hter  of  fluid  and  shaped  somewhat  hke  a  bagpipe. 
Operation:  Right  salpingectomy.  Left  salpingo-oophoreetomy.  Result  of  operation 
not  stated. 

Fraenkel,  L.  (Monats.  f.  Geb.  u.  Gyn.,  vol.  xxxv.  No.  4,  p.  459). — Age,  twenty.  Nullipara. 
Appendectomy  five  years  before  present  attack.  Fourteen  days  prior  to  operation 
severe  pain  in  lower  abdomen  and  vomiting.  Diagnosis  before  operation:  Bilateral 
ovarian  cyst,  torsion.  Operation  revealed  right  pyosalpinx  the  size  of  a  man's  fist 
and  a  twisted  pedicle.  Tube  measured  20  cm.  Left  side  similar,  but  no  torsion. 
Bactcriologic  examination. 

Francois  (Societe  Anatomique,  October  30;  La  Presse  medicale.  No.  89). — Cystic  salpingitis 
with  torsion  of  pedicle.  Abundant  hemorrhage  in  tubal  wall;  hemorrhagic  fluid  in 
cyst  cavity.     Other  tube  normal.     [No  other  data  given.] 

Frilsck,  H.  (Die  Krankheiten  der  Frau,  Braunschweig,  1894,  p.  469). — Simply  declares  that 
every  hematosalpinx  is  not  a  tubal  pregnancy  and  reports  a  very  movable  hematosal- 
pinx with  a  t«isted  pedicle,  but  gives  no  deatils.  Diagnosis:  Hydrosalpinx,  twisted, 
size  of  fist. 

Funke  (Hegar's  Beitrage,  1904,  vol.  vii.  No.  3,  p.  450). — Age,  twenty-eight.  Typhoid  fever 
at  twenty.  Abdominal  tumor  for  one-half  year,  increasing  in  size.  Diagnosis  before 
operation:  Inflamed  tumor  of  left  adnexa.  Diagnosis  after  operation:  Hydrosal- 
pinx, twisted.  Left  side  affected,  well  liidden  by  adhesions.  Right  also  hydrosalpinx, 
not  adherent,  also  twisted.  Ovary,  normal;  left  twisted  1^2  times  opposite  to  direc- 
tion of  th9  hands  of  a  watch;  right  twisted  3^  with  watch;  clear  yellow  fluid. 

Cosset  and  Reymond  (Ann.  de  Gyn.,  1899,  p.  21). — Age,  thirtj'-one.  Ill-para.  Seat  of 
tumor,  left;  size  of  fist.  Pedicle  twisted  at  2  cm.  from  uterus.  One  twists  in  direction 
contrary  to  hands  of  watch.  Contents,  chocolate-colored  fluid.  No  adhesions. 
Ovary  twisted.  Opposite  adnexa  healthy.  Objective  signs:  Sui)rapubic  ma.ss  rising 
to  five  fingers  above  [)Mliis;  slight  lateral  inol)ilily;  posterior  culdc.sac  filled  l)y  resistant 
ma.ss  corresponding  with  the  siipi;ii)iiliic-  tumor.  Pain  since  first  pregnancy,  especially 
at  periods,  .\fter  a  long  walk  suddenly  seized  with  severe  pains  in  abdomen,  most 
severe  in  left  flank,  radiating  to  lumbar  region.  Vomiting  of  food  and  bile.  Operation. 
Result,  cure. 

GouUioud  (Quoted  by  Cathelin:  Rev.  de  Chirurg.,  1901,  Xos.  2  and  3,  p.  263).— Ago, 
thirty-seven.  Nullipara.  Diagnosis  before  operation:  Pelvic  myoma  complicated  by 
ovarian  cyst.  Diagnosis  after  operation:  I''il)roma  uteri  and  hydro.salpinx,  twisted. 
Scat  of  tubal  tumor,  right,  size  of  child's  head.  Two  twists.  Contents  fluid,  hemor- 
rhagic, not  vi.scid.  Ovary  twisted.  Opposite  adnexa  cystic.  01)jectivc  signs:  .\b- 
domcn  distended;  myoma  reaching  to  umbilicus.  In  front  of  this  hard  tumor  another, 
which  is  fluctuating,  not  reaching  to  symphysis.  In  right  iliac  fossa  another  smaller 
tumor,  size  of  an  egg,  very  hard  and  tender.  For  the  eight  days  before  admission  to 
hospital  acute  pain  with  sud<len  enlargement  of  abdomen.  Pain  radiating  to  right  leg. 
Operation:  Bilateral  salpingo-oophoreetomy.  Result,  cure.  Remarks:  After  opera- 
tion, retrogression  of  fibroma  and  improvement  in  pulmonary  and  pleural  tuberculous 
lesions.     The  pelvic  infection  may  have  been  tubercular.     Not  stated. 

Guicciardi,  G.  (Ginecologia,  1905,  No.  4).— ,\ge,  forly-nine.     Single.     Left  tube  and  ovary 


348  GONORRHEA    IN   WOMEN 

and  right  ovary  adherent.  Right  sactosalpinx,  enlargement  confined  to  ampulla. 
A  number  of  twists  occurred  in  the  isthmus  of  the  tube,  and  finally  the  tube  became 
twisted  off,  lea\'ing  a  uterine  stump  3  cm.  in  length.  Guicciardi  has  seen  5  cases  of 
tubal  torsion  in  10-41  laparotomies,  with  3  actual  amputations  of  the  enlarged  tube. 

Harpoth  (Zent.  f.  Gyn.,  1900,  No.  52,  p.  1399). — Age,  twenty-six.  No  evidences  of  infec- 
tion mentioned.  Operation  six  weeks  after  acute  attack.  Diagnosis  before  operation: 
Ovarian  cyst  and  torsion;  general  health  good.  Diagnosis  after  operation:  Bilateral 
hydi-osalpinx,  left  twisted  2J2  times.  Although  not  definitely  stated,  presumably  no 
tubal,  but  a  few  omental,  adhesions.  No  bacteria  found  on  microscopic  examination 
and  no  cultures. 

Harlmaii,  H.,  and  Reymond,' E.  (Annal.  de  gyn.,  September,  1894,  vol.  xlii,  p.  172;. — Age, 
thirty.  Subjective  conditions:  Pains  in  right  side  of  abdomen.  For  last  three  years 
patient  noticed  tumor.  Occasional  severe  attacks  accompanied  by  vomiting.  Right 
hydrosalpinx  and  cystic  ovary.  Adhesions  to  surrounding  organs.  Contents,  IJ^ 
liters  sanguinolent  fluid.  Diagnosis:  Right  hydrosalpinx,  2  twists  in  cUrection  of 
hands  of  watch. 

Hartinan,  H.,  and  Reymond,  E.  (Annal.  de  gyn.,  1898,  vol.  1,  p.  161). — NulUpara.  Diagnosis 
before  operation:  Bilateral  salpingitis  I  )i,ii;iKisis  after  operation:  Bilateral  hydro- 
salpinx, left  tube  being  twisted  in  ilii  i'rii(,ii  ..pposite  to  hands  of  watch  several  times. 
This  tumor  is  dark  red,  lobulated,  aiid  i.osxs.-cs  a  pedicle  the  size  of  a  finger.  It  con- 
tained 400  grams  bloody  fluid.  A  number  of  adhesions  were  present  on  the  right  side.  . 
The  uterus  itself  was  twisted  }'^.  Objective  signs:  Increase  in  .size  of  tumor,  tender- 
ness, dulness,  and  symptoms  of  peritonitis,  with  v-iolent  pains  in  right  side  radiating 
down  thigh.     Operation:   Salpingo-oophorectomy.     Cured. 

Harlman  (Ann.  de  gynec.  et  d'obst.,  Paris,  1900,  vol.  liii,  p.  119). — Case  1. — Age,  forty- 
four.  Pains  in  right  side  of  abdomen,  coming  on  in  attacks  for  two  years.  Exam- 
ination: Subumbilical  tumor;  fluctuating.  Right  side.  Pedicle  size  of  umbilical 
cord.  Twisted  tv\ice.  Color,  brown.  Contents,  500  grams  blood.  No  mention  of 
just  what  composed  tumor — tube  (?),  ovary  (?),  both  (?).  No  mention  of  opposite 
adnexa.     Result,  cure. 

Cose  2. — Age,  twenty.  When  five  to  six  months  pregnant,  suddenly  seized  with  pain  in 
right  iliac  region;  vomiting;  distention;  fever.  Operation  next  day.  Right  adnexa 
enlarged,  adherent,  hemorrhagic.  Pedicle  twisted  once.  Removal.  Cure.  Normal 
delivery  at  term. 

Case  3. — Age,  tliirty-three.  Curetage  several  times  for  metrorrhagia.  December  7,  1899, 
sudden  \iolent  abdominal  pains;  in  following  days  signs  of  pelvic  peritonitis  gradually 
subsiding.  Tenderness  remained.  Large  mass  in  abdomen,'  reacliing  to  umbilicus. 
Operation  January  3,  1900.  Large  blackish  timior  formed  by  right  hydrosalpinx, 
with  pedicle  twisted  directly.  Ovary  not  involved.  Uterus  twisted  J-^.  Contents: 
Sterile  fluid. 

Harlman,  C.  R.  (Compt.  rend,  de  la  soc.  d'obst.  de  gyn.  psed.,  Paris,  1900,  vol.  p.  ii,  254). — 
Age,  twenty-five.  I-para  (eight  months  previous).  Diagnosis  before  operation: 
Appendicitis  or  tubal  disorder.  Diagnosis  after  operation:  Hydrosalpinx,  twisted 
(right)  J'2.  Numerous  adhesions.  Ovary  twisted.  Opposite  adnexa:  Adhesions. 
Objective  signs:  Abdomen  flaccid;  tumor  in  hypogastrium,  reaching  to  right  iliac 
fossa;  irregular;  painful.  Per  vaginam,  mass  posterior  to  uterus,  continuous  with 
abdominal  tumor.  Six  weeks  previous  to  operation  sudden  abdominal  pain  without 
vomiting;  fever.  Operation:  Unilateral  salpingo-oophorectomy.  Result,  cure. 
Remarks:  Appendix  adherent;  removed. 

Hedley,  J.  P.  (Proc.  Roy.  Soc.  Med.,  London,  1907-08,  vol.  i,  p.  95). — Age,  twenty-three. 
Single.  Acute  symptoms  came  on  in  a  tram-car.  Operation  after  seventeen  days  of 
acute  pain  in  lower  abdomen.  Removal  of  aff'eeted  tube.  Diagnosis:  Left  hydro- 
salpinx twisted  twice  in  direction  of  hands  of  watch;  size  of  small  orange.  Contents: 
Sterile,  thin,  blood-streaked  fluid.  Ovary  and  appendix  normal.  No  adhesions  men- 
tioned.    Recovery. 

Herjf,  J).  (Verhandl.  d.  Gesell.  f.  Gyn.,  Kong.,  1895,  p.  695).— Exhibited   a  specimen  of 

torsion  of  a  hydrohematosalpinx.     [No  details.] 
Hirst  (Amer.  Jour.  Obst.,  vol.  .\xxiii,  p.  263). — Left  side  affected.     Other  pelvic  organs 

normal.     No  other  details.     Diagnosis:   Hydrosalpinx  twisted  3  times,  in  association 

with  myoma  of  uterus. 

Jacobs  (Zent.  f.  Gyn.,  1896,  No.  50,  p.  1283).— Ill-defined  pain  through  lower  abdomen, 
chiefly  on  the  right  side.  At  operation  a  myoma  of  the  uterus  was  found  and  removed 
by  vaginal  morcellement.  Right  pyosalpinx  and  right  ovarian  abscess.  Tube  was 
twisted  3  cm.  from  the  uterus.     No  gangrene  was  present.     The  tubal  walls  were  thin. 


UNUSUAL   MANIFESTATION'S    AND    REMOTE    COMPLICATIONS         349 

Kadigrohow,  B.  A.  (Abst.  Zent.  f.  Gj'n.,  1907,  No.  32,  p.  991).— Age,  twenty-six.  Nulli- 
para. Right  hydrosalpinx;  slow  twisting;  almost  complete  amputation  of  tube. 
String-like  connection,  1  cm.  long.  Contents  of  tube:  bloody  fluid.  Tumor  oblong, 
disseminated  red  spots. 

Kauffmann  (Zent.  f.  Gynak.,  1903,  vol.  .xlix,  p.  139). — Age  (?).  lll-para;  one  miscarriage. 
Diagnosis  before  operation :  Retroflexion  with  adhesion.  Much  pain;  unable  to  work. 
Diffuse  adhesions  of  both  adnexa.  Right  side  affected;  consisted  of  two  parts,  a  short 
uterine  stump  and  an  outer  portion,  3  cm.  long,  with  fimbriated  extremity  closed. 
Diagnosis  after  operation:   Right  hjdrosalpinx  detached  by  torsion. 

Klein  (Monats.  f.  Geb.  u.  Gyn.,  1912,  p.  655). — Age,  thirty-five.  Il-para.  Diagnosis 
before  operation:  Ovarian  cj'st;  twisted  pedicle.  Three  attacks  of  pelvic  peritonitis 
pre\iously.  Diagnosis  after  operation:  Hydrosalpinx,  twisted  360  degrees;  ovary 
adherent;  bluish-black  tumor. 

Legueu  and  Chabry  (Rev.  de  Gyn.  et  de  Chir.  abdom.,  1S97,  No.  1,  p.  11). — This  case  appears 
to  be  the  same  as  Case  1  in  Presse  medicale,  1900,  p.  137.  Alultipara.  Sj-mptoms  of 
pelvic  inflammatory  disease  for  some  time  prior  to  attack.  Sudden  onset  of  pain  in 
ovarian  region.  Diagnosis  before  operation:  Ovarian  cyst  with  a  twisted  pedicle. 
Operation  showed  a  large  hj-drosalpinx  twisted.     Opposite  adnexa  normal.     Recovery. 

Leyueu  (Presse  medicale,  1900,  p.  37). — Case  1. — Age,  thirty-three.  Ill-para.  Diagnosis 
before  operation:  Ovarian  cyst  with  a  pyosalpinx.  Diagnosis  after  operation:  Hydro- 
salpinx, twisted.  Contents,  400  grams  blood;  ovary  not  twisted.  Opposite  adnexa 
healthy.  Objective  signs:  Above  and  to  right  umbilical  tumor  with  rounded  upper 
margin,  whose  lower  end  reaches  into  small  pelvis.  On  palpation,  resistant,  tender; 
hanlly  to  be  felt  per  vaginam.  Subjective  conditions:  Sudden  pains  at  menstrual 
pcrind,  especially  in  the  right  side;  vomiting  of  food  and  bile.  Operation:  Unilateral 
.^alpingo-oophorectom}'.  Result,  cure. 
'  'ii.-ic  4. — Age,  t wentj'-six.  Diagnosis  after  operation :  Right  hydrosalpinx,  size  of  hen's  egg. 
Form  smooth,  regular.  Twists,  1^2  times.  No  adhesions.  Ovary  not  twisted. 
Objective  signs:  Mobile  tumor,  slightly  tender,  in  posterior  culdesac,  independent  of 
uterus.  Subjective  conditions;  acute  pains  in  abdomen  at  menstrual  periods  for  past 
two  years,  especially  right.  Leukorrhea  only  during  intervals.  Operation:  Unilateral 
salpingo-oophorcctomy.     Result,  cure. 

Lejars  (La  Gyn.,  January,  1910,  p.  70;  and  Compt.  rend,  de  la  soc.  d'obst.,  gyn.,  p;pd., 
Paris,  1909,  vol.  xi,  p.  342). — Case  1. — Age,  thirty-two.  Diagnosis  before  operation: 
Fibroma  (retroperitoneal).  Subjective  conditions:  Three  years  previous,  suddenly 
taken  with  pains  in  al)domen  which  lasted  several  days.  Reappeared  at  menstrual 
periods  and  when  fatigued.  Three  months  before  operation  severe  attack;  bed  for 
ten  daj's.  Objective  findings:  Ma.ss  size  of  fist  anterior  and  to  left  of  uterus.  At 
operation:  Large,  Ijlackish  tumor  anterior  and  left  of  uterus,  everywhere  adherent  and 
corresponding  to  left  adnexa,  attaciied  to  left  cornua  by  pedicle  twisted  twice,  under- 
going ulceration.     [Xo  micnwcopic  examination.) 

' -rvK  2. — Age,  thirty-one.  Ill-para.  No  pain  until  two  weeks  before  operation;  sudden 
onset.  Objective  Hndings:  Cervix  large,  hard;  in  right  culdesac  ma.-ss  size  of  two  fists, 
hard,  fixed.  Operation:  Mass  consists  of  large  tube  twisted;  loop  of  intestine  adherent. 
<  'ontents,  pus. 

i<c  3. — Age,  thirty-eight.  Nullipara;  no  miscarriages.  Severe  pains;  sudden  onset  .six 
weeks  before  admission.  IC.xaminalion:  Nodular,  hard  tumor,  fixed,  reaching  to  three 
fingers  below  umbilicus,  filling  left  iliac  fo.ssa.  Operation:  Myoma  with  many  in- 
testinal adhesions;  left  tube  large,  blackish,  external  half  twisted,  the  torsion  being 
maintained  by  fine,  recent  adhesions.  Opposite  adnexa  normal.  Operation:  Hyster- 
ectomy and  bilateral  salpingo-oophorcctomy.     Cure. 

Case  4. — Age,  fifty.  Ill-para.  One  miscarriage.  For  two  months  profuse  metrorrhagia; 
leukorrhea.  No  severe  pains;  general  feeling  of  weight  in  abdomen.  Examination: 
Large  adhircnl  ina.-^s  in  pouch  of  Douglas,  wiiich  appeared  to  be  in  large  part  consti- 
tuted Ijy  Miniflcxfd  uterus.  (Jperation:  Uterus  retroverted;  on  left,  a  prolap.sed, 
blackish  tube  lilled  with  hemorrhagic  fluid,  twisted  several  times  on  its  peilicle.     Ciire. 

Case  5. — Age,  forty-three.  Operated  upon  for  uterine  myoma.  Hilateral  hydrosalpinx 
size  of  lemons,  each  tube  twisted  on  its  pedicle. 

Case  0. — Age,  forty.  History  and  .symptoms  of  chronic  salpingo-oophorilis.  Operation: 
Right  ovarv  healthy;  "the  lube  iii  its  inner  three-<|Uarters,  healthy;  (he  ampulla  was 
transformed  into  a"  little  blackish  pou<ii,  attached  to  a  twisted  pedicle,  and  in  part 
delacheil."  Contents  of  the  little  ijoucli  black,  hemorrhagic  li(iui<l,  mixed  with  a 
little  pus.  Diagnosis:  Salpingitis,  torsion,  necrosis.  Tlio  torsion  and  rupture  had 
been  eccentric  and  had  involved  only  the  ampulla.  Opposite  adnexa:  Cystic  ovary, 
tube  large,  closed. 


350  GONORRHEA    IN   WOMEN 

Case  7. — Age,  twenty.  Pains  in  right  abdomen  came  on  one  month  before  operation. 
Painful  micturition.  Examination:  Round  tumor  in  suprapubic  region  (right),  size 
of  an  orange;  consistence  of  dermoid,  which  wa.s  the  clinical  diagnosis.  Operation: 
Large  hydrosalpinx  of  left  side,  transposed  to  right,  twisted  3  times  on  itself; 
torsion  maintained  by  adhesions.  Ovary  healthy.  Opposite  adnexa  normal;  uterus, 
small.  Result,  cure. 
Lewers  (Trans.  London  Obst.  Soc,  vol.  xliv,  p.  362). — Age,  thirty-seven.  Single.  First 
attack  of  pain  and  vomiting  December,  1901;  second.  May,  1902;  third,  September, 
1902.  Diagnosis  before  operation:  Bilateral  ovarian  tumor  with  twist  of  pedicle. 
Diagnosis  after  operation :  Bilateral  pyosalpinx,  torsion  on  right  side  and  adhesions  to 
small  intestine  and  bladder.  Operation:  October,  1902,  bilateral  salpingectomy. 
Diagnosis:  Pyosalpinx  twisted  several  times.     Right  ovary  not  involved. 

Maillard  (These  de  Paris,  1893  and  1897,  quoted  by  Legueu,  Presse  m6d.,  1900,  p.  37— 
second  case). — Age,  forty-nine.  Ill-para;  last,  seventeen  years  previous.  Diag- 
nosis before  operation:  Pyosalpinx,  right,  with  less  severe  adnexal  disease,  left. 
Diagnosis  after  operation:  Right  hematosalpinx;  twisted  pedicle  13^2  times  in  direction 
of  hands  of  watch.  Form,  globular.  Ovary  normal.  Contents,  coagulated  blood. 
Opposite  adnexa:  Ovary  cystic.  Objective  signs:  Uterus  three  fingers  above  symphy- 
sis. Tumor  felt  high  in  right  culdesac,  size  of  egg,  resistant.  Attached  to  uterus  on 
one  side,  to  pelvic  wall  on  other.  In  left  culdesac  a  smaller,  long  tumor,  attached  to 
uterus,  slightly  tender.  Subjective  symptoms:  Menstruated  at  age  of  tliirteen.  Four 
years  before  operation  leukorrhea,  pain  on  urination,  tenesmus;  diagnosis  of  gonorrhea. 
Shortly  afterward  began  to  have  abdominal  pains,  which  for  last  year  have  considerably 
increased.  These  came  on  in  attacks,  always  beginning  on  right  side,  radiating  to 
lumbar  region,  and  down  tliigh  to  knee;  vomiting;  distention  of  abdomen;  attacks 
lasted  three  days,  gradually  passing  into  period  of  calm,  generally  lasting  about  one 
and  one-half  months.  In  year  preceding  operation  had  had  7  attacks.  Result,  cure. 
Operation:  Supravaginal  hysterectomy,  bilateral  salpingo-oophorectomy.  Remarks: 
Myoma  of  uterus  present. 

Martin  (Compt.  rend,  de  la  soc.  d'obst.,  gyn.,  peed.,  Paris,  1906,  vol.  viii,  p.  147). — • 
Age,  thirty-four.  Nullipara.  Thought  herself  four  months  pregnant  and  threatened 
with  miscarriage.  Past  four  or  five  months  distention  of  abdomen,  accompanied  with 
diminution  in  menstrual  flow.  Nausea  and  vomiting  in  morning.  Just  before  ad- 
mission suddenly  seized  with  violent  abdominal  pains;  vomiting.  Examination: 
Uterus  normal  in  size.  In  right  culdesac  a  rounded,  fluctuating  tumor,  tender,  distinct 
from  uterus.  Diagnosis  before  operation:  Torsion  of  pedicle  of  small  ovarian  cyst, 
or  probably  a  right  salpingitis.  Operation:  Smooth,  fluctuating  tumor  in  pouch  of 
Douglas  with  no  adhesions,  which  proved  to  be  a  right  hydrosalpinx;  ovary  not  in- 
volved.    Opposite  adnexa  normal.     Tube  measures  11x9  cm. 

Mclllroy  (Scottish  Med.  and  Surg.  Jour.,  August,  1904,  p.  150). — Age,  forty-three.  Mar- 
ried. V-para.  Last  labor  eleven  months  ago.  Attack  of  pain  during  last  pregnancy, 
and  felt  as  if  there  was  some  obstruction  to  last  dehvery.  Thereafter,  pressure  symp- 
toms. Left  side  affected.  Diagnosis  after  operation:  Hydrosalpinx;  outer  third  of 
tube  enormously  distended;  3  twists  of  tube  at  different  parts  in  direction  of  hands  of 
watch;  outer  third  necrotic.  This,  Mclllroy  believed,  was  a  parovarian  cyst,  but  on 
studying  the  case  more  carefully  believes  it  tubal.  Complete  torsion  of  tube  at  three 
distinct  points;  necrosis  of  outer  cystic  part,  containing  chocolate-colored  fluid  and 
flakes  of  fibrin.  Parovarium  distinct.  Drawing  resembles  a  parovarian  cyst,  but 
author  regards  it  as  a  hydrosalpinx. 

Mclllroy,  A.  C.  (Jour.  Obst.  and  Gyn.  Brit.  Emp.,  1910,  vol.  x\'iii,  p.  368;  also  Proc.  Roy. 
Med.  Soc.  London,  1910-11,  Obst.  and  Gyn.  Sec,  p.  1121). — Age,  forty-six.  IV-para; 
last,  twenty  years  ago.  Severe  pain  in  left  ihac  region,  which  came  on  suddenly  five 
days  ago.  Chills  and  some  symptoms  of  collapse.  Menstruation  irregular.  Exam- 
ination: Mass  as  large  as  orange.  Diagnosis:  Myoma  of  uterus  or  tubo-ovarian  tu- 
mor. Operation :  Uterus  enlarged  and  mass  size  of  orange  adherent  to  posterior  uterine 
wall,  which  proved  to  be  a  left  hematosalpinx.  Two  twists  in  uterine  end.  Ovary 
not  involved.     Recovery. 

Michel  (Ann.  de  Gyn.  et  d'obst.,  1907;  ref.  Zent.  f.  Gyn.,  1909,  vol.  xxiv,  p.  863).— Age, 
thirty-five.  Married.  Il-para.  Operation:  Four  weeks  after  first  attack.  Both 
sides  affected.  No  pus  in  tubes,  although  had  fever.  Diagnosis:  Hydrosalpinx,  right; 
twisted  4  times.     Hematosalpinx,  left;  twisted  3  times. 

Montgomery,  E.  E.  (Amer.  Jour.  Obst.,  1912,  vol.  Ixvi,  p.  272). — Age,  twenty-two.  Pre- 
sented symptoms  suggestive  of  ectopic  pregnancy.  Operation  showed  a  left  pyo- 
salpinx, probably  gonorrheal  in  origin,  with  torsion. 


I 


UNUSUAL   MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         351 

Morel  (Bull,  et  m6m.  de  la  soc.  anat.  de  Paris,  December,  1903,  p.  863). — Age,  thirty-two. 
IV-para.  Diagnosis  before  operation:  Ectopic  pregnancy.  Subjective  conilltions: 
Had  missed  no  period.  Severe  pain  on  left  side,  spreading  to  entire  abdomen.  Vomit- 
ing bile.  Examination  of  abdomen:  Rigid,  tender.  Mobile,  tender  tumor  in  posterior 
culdesac.  Operation  (next  day) :  Uterus  large,  appears  gravid.  Right  adnexa  normal. 
Posterior  culdesac  occupied  by  a  mobile,  \iolet-colored  tumor,  developed  from  left 
adnexa,  size  of  turkey-egg.  Pedicle  twisted  5  or  6  times.  Wall  of  tubal  sac  delicate, 
and  the  hemorrhagic  contents  can  be  seen  through  it.  [No  anatomic  diagnosis;  ectopic 
(?);  hematosalpinx?] 

Nanu  (Bull,  et  mf-m.  de  la  soc.  de  cliir.  de  Bucarest,  1900,  p.  160). — Trans.:  "M.  Nanu 
presented  a  specimen,  obtainetl  by  abdominal  hysterectomy,  of  a  uterine  myoma  ^\-ith 
both  tubes.  One  of  these,  a  right  hematosalpinx,  has  the  pedicle  twisted"  about  its 
axis;  it  occupied  the  position  of  the  cecum,  which  it  resembles  in  form.  It  has  also 
adhesions  to  the  omentum." 

Orlner  (Zent.  f.  Gyn.,  1909,  vol.  xxix,  p.  1025). — Age,  thirty.  Symptoms  acute,  followed 
straining  at  stool.  Chills,  vomiting,  and  pain.  Operation  after  six  days.  Mass 
palpated  a  month  before.  Left  tube  thick  as  ball  of  thumb,  swollen,  and  dark  blue; 
mucosa  necrotic.  Tube  twisted  about  2  cm.  from  uterus,  IK  times  in  direction  of 
watch.  Right  tube,  abdominal  ostium  closed  and  contained  pus.  Omentum  adherent 
to  fundus.  Left  ovary  normal.  Hemorrhagic  infarcts  in  tube  wall;  tube  seat  of  tor- 
sion, and  contained  pus  and  blood. 

Pierson  (Reported  by  Storer,  Boston  Med.  and  Surg.  Jour.,  1896,  vol.  cxxxv,  Xo.  19,  p.  461). 
— Diagnosis:  Acute  appendicitis.  Right  side  affected.  Pyosalpinx,  which  lay  above 
pelvic  brim,  with  fimbriated  extremity  looking  toward  the  loin.  Diagnosis:  Pyosal- 
pinx twisted  1}'2  times,  close  to  uterine  end. 

Finard  and  Paquy  (Compt.  rend,  de  la  soc.  d'obst.,  gj'n.,  paed.,  Paris,  October,  1901;  ibid., 
1902). — The  age  in  one  reference  is  thirty-six  and  in  the  other  twenty-six,  but  all  other 
details  are  the  same.  I-para.  Numerous  severe  attacks  of  pain  during  the  second 
Ijregnancy  and  for  past  five  years;  vomiting  in  last  attack;  pain,  nausea,  frequent 
micturition,  vomiting,  diarrhea,  meteorism,  and  icterus.  Operation  after  induction 
of  labor  aiicl  ein[)t ying  of  titerus  because  symptoms  continued,  especially  fever.  Right 
side  affected.  Right  salpingo-oophorectoniy.  Pregnant  uterus.  Diagnosis:  Hyciro- 
salpinx  twisted  twice,  reversely  to  hands  of  watch;  size  of  orange.     Ovary  normal. 

Poirier  el  Calhelin  (Bull.  Soc.  Anat.  de  Paris,  1900,  p.  209). — Age,  forty-two.  Ill-para; 
last,  twelve  years  previous.  Diagnosis  before  operation:  Retroflexcd  uterus  or  prob- 
ably adnexal  disease.  Diagnosis  after  operation:  Left,  pear-shaped,  nodular  hydro- 
salpinx, size  of  orange.  Twisted  3J4  times.  Ovary  also  twisted.  Objective  signs: 
Resistant  abdominopelvic  tumor.  Subjective  conditions:  Menstruated  at  twelve; 
irregular;  active  pains;  metrorrhagia.  Operation:  Bilateral  salpingo-oophorectomy. 
Result:   Death  next  day.     Remarks:  Autopsy  did  not  reveal  cause  of  death. 

Polak,  J.  O.  (Amer.  Jour.  Obst.,  1912,  vol.  Ixvi,  p.  272).— Age,  nineteen.     Acute  onset  of 
.  symptoms.     Operation  three  days  later.     The  tube  had  been  converted  into  a  hema- 
tosalpinx and  measured  10  x  8  cm.     Torsion.     The  ovary  was  not  involved. 

Pozzi  (Compt.  rend,  de  la  soc.  d'obst.,  gyn.,  pa!d..  Paris,  1900,  p.  201). — Age,  thirty-seven. 
Ill-para.  In  1891  metritis  following  chilling  during  menstrual  period.  Extra- 
peritoneal evacuation  of  pus  from  left  iliac  region.  Regained  health.  December, 
1899,  fever,  vomiting,  pain  midway  between  umbilicus  and  anterior  supeiior  spine. 
Tumor  size  of  iiiunilarln  at  McHurney's  point.  Diagnosis  before  operation:  .Appendi- 
citis. First  operation,  January  1,  1900:  Right  pyohematosalpinx  size  of  orange, 
twisted  once.  Ojjposite  adnexa  not  examined  (right  ovary  also  twisted).  Conva- 
lescence normal  until  January  11th.  T'ain  left  iliac  region,  beneath  .scar  of  operation 
in  1891,  fever.  .Second  operation  January  14,  1900.  Left  iliac  incision.  Pus  cavity 
adherent  to  scar.  Pyosalpinx  blackish  in  color,  twisted  once.  Ovary  carried  down  and 
forward;  tube  up  and  backward.  Resembles  adnexa  of  opposite  side.  Salpingo- 
oophorectomy.     Result,  cure. 

Pozzi  (Compt.  rend,  de  la  soc.  d'obst.,  gyn.,  pad,  Paris,  1900,  vol.  ii,  p.  95). — This  is  same  as 
case  in  l{ev.  de  gyn.  et  chir.  abd.,  April  10,  1900,  p.  160.  Age,  thirty-three.  I-para 
(forceps).  Subjective  conilltions:  Metritis  at  age  of  twenty-eight,  from  time  to  time 
thereafter  attacks  of  pain  lasting  two  wi^eks  at  a  time,  not  at  menstrual  periods.  Janu- 
ary, 1900,  very  sever<'  pains  in  lower  abdomen.  From  then  on  several  attacks  of  ab- 
dominal pain  and  constant  bleeding  until  operation.  Objective  findings:  Cervix 
large,  .soft,  patulous.  Uterus  large;  to  left  and  In  front  of  uterus  a  cyst  size  of  fetal 
head;  on  right,  .slight  Induration.  Diagnosis  before  operation:  Ovarian  cyst,  left;  .sal- 
pingitis,  right.     Operation:    April  2,    1900.     Large  tumor  resembling  ovarian  cyst 


352  GONORRHEA    IN    WOMEN 

found  on  left  side,  but  pedicle  arises  from  right  and  proved  to  be  an  enormously  dilated 
tube  weighing  300  grams,  twisted  once  reversely  to  hands  of  watch.  Ovary  sclero- 
cystic.  Opposite  adnexa:  Ovary,  normal;  tube,  hydrosalpinx.  Bilateral  salpin- 
gostomy. Result,  cure. 
Praeger,  J.  (Arch.  f.  Gyn.,  1899,  vol.  Iviii,  p.  579). — Case  1. — Age,  twenty-two.  Nullipara. 
Suffered  with  delayed  menses  and  distress  in  lower  abdomen  July,  1897.  In  October, 
1897,  ovarian  tumor  cUagnosed;  acute  attack  April,  1898,  vomiting,  constant  and  severe 
pain.  Operation  three  months  later.  Diagnosis  before  operation:  Adherent  ovarian 
or  tubal  mass.  Left  ovary  and  tube  removed;  right  ovary  resected;  right  salpingot- 
omy. Diagnosis:  Left  hydrosalpinx  twisted  twice  in  direction  of  hands  of  watch. 
IDark-red  color;  hemorrhagic  infiltration.  Ovary  involved.  Numerous  adhesions. 
Case  2. — Age,  thirty-five.  I-para.  Nopainprior  to  February,  1899;  thereafter,  amenor- 
rhea for  twelve  weeks;  severe  pain;  constant  vomiting;  retention  of  urine.  Tumor 
in  left  abdomen  found.  Since  then  great  tenderness  over  abdomen;  tumor  reaching 
to  umbihcus  on  left.  Chnical  diagnosis:  Left  ovarian  cyst  with  torsion.  Operation, 
February  23d.  Tumor  measiu-es  10  x  10  x  7  cm.  Diagnosis:  Left  hydrosalpinx, 
twisted  twice  in  direction  of  hands  of  watch.  Contents:  Blood  and  bloody  masses; 
hemorrhagic  infiltration.     Ovary  not  involved.     Right  side  normal. 

Ries  (Amer.  Gyn.  and  Obst.  Jour.,  April,  1900,  p.  325). — Age,  thirty-two.  Married.  One 
child  eleven  years  ago;  two  miscarriages,  one  twelve  and  one  eight  years  ago.  Ailing 
since  first  labor.  Attack  of  severe  pain  four  years  ago;  in  bed  a  week.  Diagnosis 
before  operation:  Inflamed  right  adnexa.  Right  tube  was  found  to  have  been  con- 
verted into  a  hematosalpinx,  size  of  egg,  which  has  been  spontaneously  amputated  by 
torsion.     Numerous  adhesions.     Both  ovaries  removed  because  of  peri-obphoritis. 

Rouffarl,  E.  (Bull.  Soc.  Gyn.  and  Obst.,  Brus.sels,  1900,  tome  x.  No.  10,  p.  257).— Age,  forty. 
Il-para;  last,  eighteen  months  previous.  Diagnosis:  Retroversion  of  uterus.  Left 
pyosalpinx  size  of  orange,  blackish  in  color.  Ovary  not  twisted.  Retroposition  of 
uterus.  Adhesions  to  rectum  and  lower  portion  of  ileum.  Right  pyosalpinx 
adherent  to  rectum.  Objective  signs:  Cervix  patulous;  retroversion.  Tumor  an- 
terior to  left  of  uterus,  fluctuating.  Subjective  conditions:  Menstruation  began  at 
ten  years;  regular;  recently  paroxysmal  pains  on  left  side  low  down.  Operation: 
Supravaginal  hysterectomy  and  bilateral  salpingo-oophorectomy.     Result,  cure. 

Rouffarl  (Jour.  med.  de  Bruxelles,  1900,  No.  12;  ref.  Zent.  f.  Gyn.,  1900,  vol.  xxxvii,  p.  975). 
— Age,  twenty-six.  I-para.  Complete  separation  outer  part  of  right  tube  as  a  conse- 
quence of  torsion,  probably  a  previous  hydrosalpinx;  separated  part  adherent  and 
parasitic;  ovary  adherent.     Left  parovarian  cyst. 

Sampson,  J.  A.  (Amer.  Jour.  Obst.,  August,  1912,  p.  271). — Case  in  wliich  the  symptoms 
pointed  to  an  acute  pelvic  condition  on  the  right  side.  At  operation  the  right  tube 
was  found  to  be  the  seat  of  the  trouble,  and  was  twisted  and  enlarged  to  probably 
twice  its  original  size.  Right  salpingo-oophorectomy.  The  patient  was  nineteen  years 
of  age. 

Sanger  (Zent.  f.  Gynak.,  1893,  No.  31,  p.  727). — Age,  thirty-nine.  No  children.  For  some 
time  irregular  menorrhagia  and  metrorrhagia.  Acute  pain  in  left  adnexa.  Operation 
after  two  months;  no  fever;  vomiting.  Bilateral  salpingo-oophorectomy.  Leftside 
affected.  Right  side  inflamed;  sm.-ill  hyilidsalpinx.  Diagnosis:  Bilateral  hydro- 
salpinx; Right  tube  size  of  an  apiilr  wiih  luliiieral  adhesions;  hemorrhagic  infarction 
from  obstructed  circulation.  San{;cr  attributed  hematosalpinx  and  hemorrhagic 
necrosis  in  tliis  case  to  the  torsion. 

Siredy  (Compt.  rend,  de  la  soc.  d'obst.,  gyn.,  de  paed.,  Paris,  1906,  vol.  viii,  p.  150). — In 
discussing  Martin's  case,  Siredy  reports  the  following:  Patient  (age  not  given)  had 
no  symptoms  whatever  from  genital  tract.  While  at  a  watering-place,  taken  with 
enteritis;  the  local  physician  found  by  accident  a  timior  the  size  of  adult's  fist  in  left 
side.  Patient  had  no  pain  or  symptoms  whatever,  but  subsequently  decided  to  be 
operated  on.  At  operation  a  cystic  hydrosalpinx  with  tliin  walls,  twisted  twice,  was 
found. 

Stark  (Jour.  Obst.  and  Gyn.  Brit.  Emp.,  1911,  vol.  xix,  p.  258). — Age,  forty-six.  Nulhpara. 
Attacks  of  pain  for  nine  months.  Clinical  findings:  "To  right  of  uterus,  tense  firm 
body,  size  of  ordinary  tomato;  on  left  side,  marked  enlargement  of  the  tube.  At 
operation,  blood-clots  in  lower  abdomen  and  a  left  hematosalpinx  twisted  3  times. 
Ovary  closely  applied  to  tube.     Right  dermoid  cyst,  intraligamentous. 

Stolz  (Monats.  f.  Geb.  u.  Gyn.,  1899,  vol.  x.  No.  2,  p.  175).— Age,  twenty-three.  Single. 
Right  side  normal.  Diagnosis:  Left  hydrosalpinx;  diameter  about  12  cm.  and  con- 
taining three-quarters  liter  of  clotted  blood  and  reddish-brown  fluid.  Twist,  540  de- 
grees; slow  torsion.     Operation:  Left  salpingo-oophorectomy. 


UNUSUAL   MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         353 

Storer  (Boston  Med.  and  Surg.  Jour.,  1906.  vol.  cliv,  Xo.  11,  p.  285). — Age,  twenty-nine. 
Married  si.x  years.  Xo  pregnancies.'  Xo  l\istory  of  gonorrliea.  For  a  j-ear  dull  pain 
in  left  side;  recently  pain  before  menstruation.  Diagnosis  before  operation:  Left 
salpingitis;  right  hydrosalpinx.  Both  tubes  twisted;  right  side,  no  actual  strangula- 
tion; left  side,  decided  strangulation.  Hemorrhagic  infiltration  and  infarction  on  left 
side.  X'^either  ovary  involved.  Diagnosis:  Hydrosalpinx  ^bilateral;;  right  twist 
360  degrees,  follows  hands  of  watch;  left  hydrosalpinx  twisted  ISO  degrees,  direc- 
tion opposite  to  hands  of  watch. 

Slratz  (Zent.  f.  Gynak.,  1907,  Xo.  31,  p.  1444). — Age,  thirty-six.  Ill-para;  last,  twelve 
years  ago.  February,  1901),  after  moving,  profuse  bleeding  and  pain  in  right  side. 
Operation:  March  22d.  Diagnosis  before  operation:  Right  tubal  enlargement; 
hydrosalpinx,  pyosalpinx,  or  tul)al  pregnancy.  Right  side  affected;  left  side,  normal. 
Diagnosis :  Hydrosalpinx  twisted  forward  over  round  ligament  and  adherent  to  bladder. 
Contents  partly  pus.  Microscopic  diagnosis:  Chronic  salpingitis  with  torsion  and 
formation  of  hematosalpinx.     Bluish-red  tumor. 

Taylor  (Trans.  Brit.  Gyn.  Soc,  Jour.  Obst.  and  Gyn.  Brit.  Emp.,  1S93-94,  vol.  ix,  p.  418).— 
Age,  thirtj-.  Married  at  nineteen;  child  at  twenty.  Had  retroflexion  and  sterility 
for  last  seven  years.  Taylor  did  Alexander  operation;  the  patient  .shortly  after  be- 
came pregnant  and  was  confined  at  term.  Two  or  three  months  after  had  abdominal 
pain  and  tumor  was  found.  Xo  record  of  histologic  examination.  Possibly  a  cyst  of 
tube,  but  he  says  presumably  a  hj'drosalpinx  with  twisted  pedicle. 

Veil  (V'erh.  d.  d.  Ges.  f.  Gyn.,  1S91,  vol.  iv,  p.  216). — Age,  twenty-seven.  Three  children. 
Suffered  since  last  labor,  two  years  previous.  Sudden  attack,  severe  pain  in  abdomen; 
seven  weeks  after  first  attack,  another;  four  weeks  later,  a  tumor,  reaching  to  umbiUcus, 
was  found.  Diagnosis  before  operation:  Torsion  of  ovarian  cyst.  Diagnosis  after 
operation:  Right  hydrosalpinx  twisted,  filled  with  blood. 

Vernii  (Th&se  de  Paris,  1911-12,  vol.  xlii). — Case  1. — Previously  reported  liy  Martin. 
Case  J. — Symptoms  of  pelvic  peritonitis.     Siidden  onset  of  acute  symptoms,  with  severe 

pain    over    affected    area.     Operation    showed    a    twisted    hydrosali)inx.     Salpingo- 

oophorectomy.     Recovery. 
Case  3. — Symptoms  similar  in  general  character  to  Case  2.     Diagnosis  after  operation: 

Torsion  of  a  hydrosalpinx.     Salpingo-ociphorectomy.     Recovery. 

Voiyl  (Der  Frauenarzt,  1909). — Age,  sixty.  Tumor  noticed  for  some  time;  full  feeling  in 
abdomen;  acute  pain  and  tenderness.  Diagnosis  before  operation:  Large,  uni- 
locular ovarian  cyst,  size  of  man's  head,  twisted  pedicle.  Diagnosis  after  operation: 
Left  hydrosalpinx  twisted  2}2  times  and  contained  4  liters  yellow,  straw-colored  fluid; 
tumor  has  a  dark-blue  color  from  hemorrhagic  infiltration. 

Walth  (Amer.  Jour.  Obst.,  August,  1901,  p.  179). — Case  1. — Age,  .seventeen.  .Vcute  attack; 
previously  good  health.  Operation  two  days  after  onset  of  attack.  Diagnosis  before 
operation:  Acute  appendicitis.  Fever;  rapid  pulse;  tumor  in  right  iliac  fossa;  vomit- 
ing. Diagno.«is  after  operation:  Right  hydro.salpinx  twisted  3  times;  almost  com- 
pletely aiiiputat<vl  by  strangulation;  left  side,  normal;  no  ligature  needed  to  control 
bleeding  from  pedicle,  as  amputation  was  almost  completed  by  the  torsion. 
Cage  2. — Age,  twenty-six.  Married  fouryears;  never  pregnant.  Well  until  three  months 
previous.  Since  then,  pain  low  down  on  left  side.  Fever;  increased  pulse;  pain  over 
entire  lower  abdomen,  especially  left.  Abdominal  tumor  immovable,  but  slight 
fluctuation,  reaching  from  symphysis  nearly  to  umbilicus.  Diagnosis  before  operation: 
Inllamed  ovarian  cyst.  Operation  two  weeks  after  attack.  Diagnosis:  Ix-ft  hydro- 
sali)inx  infiltrated  with  blood,  with  .several  distinct  and  complete  twists.  Kxtcnsive 
adhesions.     No  villi.     Ovaries  and  left  tube  normal. 

Ward,  F.  N.  (Amer.  Jour.  Obst.,  1910,  vol.  Ixiii,  p.  639).— Case  /.- Age,  forty-.seven. 
Married  twenty-one  years.  No  children.  \\\A\  until  recently,  except  for  sharp  attack 
of  pain  in  left  ovarian  region  eight  years  liefore;  occasional  recurrence.  Kxciting 
cause  of  this  attack,  cleaning  hou.se  and  sweeping.  Acute  pain  and  symptoms  of  diffu.se 
peritonitis.  Diagnosis  before  operation:  Ovarian  cyst,  twisted  pedicle.  Diagnosis 
after  operation:  Left  hydrosalpinx  twisted  three  times;  left  ovary  involved;  right 
hydro.salpinx;  right  ovary,  normal.  Free  fluid  blood  in  abdomen. 
<'(iHe  2.^\f[f,  twenty-two.  Marric(l  four  months;  pregnant  four  months,  .\ttack  during 
pregnancy,  characterized  by  nau.sea,  vomiting,  pain  in  lower  right  alxlonicn.  Tempera- 
ture, 101°  F.;  pulse,  1  11).'  Tender  mass  in  right  side  of  pelvi.s,  beside  the  pregnant 
uterus.  Presented  the  picture  of  diffuse  peritonitis  cau.se<l  liy  acute  ap|)endii'ilis. 
Diagnosis  after  operation:  liight  hydro.salpinx  twisted  4  times,  gangreni;.  UIooil- 
slaineil  fluid  present  in  the  peritoneal  cavity.  Operation:  Right  salpingotomy, 
drainage.  Recovery. 
23 


354  GONORRHEA    IN    WOMEN 

Warnek  (Rev.  Aunal.  de  Gyn.,  1894,  No.  41,  p.  335).— Cuse  .2.— Age,  thirty.  Ill-para; 
first  attack,  six  years  ago;  last,  five  months  |)rcvimisly.  Diagnosis  before  operation: 
Pyosalpinx.  Diagnosis  after  operation:  Ivislit  hydrosalpinx  size  of  potato,  torsion. 
Contents:  Outer  two-thirds,  dots;  inner  onr-tliinl,  serous  fluid;  small  abscess  in  wall 
of  outer  two-thirds.  Opposite  adnexa  healthy. 
Case  3. — Age,  forty.  NuUipara.  Diagnosis  before  operation:  Bilateral  ovarian  cyst  with 
twisted  pedicle.  Diagnosis  after  operation:  Large  right  hydrosalpinx,  somewhat 
Ividney  shaped,  twisted  43^2  times.  Ovary  not  involved.  Opposite  adnexa:  Tubo- 
ovarian  cyst,  intraligamentous. 

Weir  (Araer.  Jour.  Obst.,  August,  1901.  p.  .520). — Age,  forty-six.  Married;  two  mis- 
carriages. Previously  well.  Aculi'  :iii:Mk;  severe  pain  in  right  lower  abdomen; 
nausea;  difficult  micturition.  Diati:iin>i,,  Ij.lnrc  operation:  Ovarian  cyst.  Operation 
five  days  after.  Right  hydrosalpin.\  twisled  twice.  Dark  red  in  color;  hemorrhagic 
infiltration  left  side  of  tube  and  ovary  adherent,  otherwise  ovary  normal. 

WilUainsiin  (Trans.  Obst.  Soc.  London,  1905). — Age,  eighteen.  LTnmarried.  Healthy 
until  December,  1903;  from  that  time  to  June,  1904,  scanty  and  painful  menses. 
.June  7th,  severe  pain  in  right  side;  later,  diffuse  pain,  vomiting,  and  distention. 
Operation  after  two  days.  Right  hydrosalpinx  twisted  3  times,  direction  opposite  to 
hands  of  watch.  Contents:  Blood;  inner  surface  smooth.  Ovary  (right)  congested, 
otherwise  normal. 

Woolcomhc  (Lancet,  December  7,  1901,  p.  1584). — Age,  twenty-two.  LTnmarried.  First 
attack  two  years  before  in  right  lower  abdomen.  Repeated  attacks  since;  last  one 
week  before  admission.  Abdominal  tumor  observed  for  two  or  three  months.  On 
right  side  abdominal  tumor  extends  abov(^  the  umbihcus;  left  side  also,  abdominal 
tumor  rising  out  of  pelvis.  .Vilhisiinis  \cry  (■asily  separated.  Diagnosis:  Pyosalpinx 
(l)ilatcrall ;  right  side  with  o\;iiy  twisted  1  '  2  times.  Left  side  without  ovary  twisted 
twice.  Right  tube,  circumference,  10 '2  inches;  extreme  length,  8  inches;  dark  bluish- 
red  blood  inside.  Right  ovary  involved;  measures  3x3  inches.  Left  tube,  the  bul- 
bous part,  7^2  inches  long.  Maximum  circumference,  11  inches.  Contents  resemble 
cream  cheese;  no  odor;  no  diplococci;  no  tubercles;  no  chorionic  villi  or  signs  of  new- 
growth. 

Further  reference.s  to  torsion  of  inflammatory  lesions  of  the  ad- 
nexa, the  original  references  to  which  have  been  unobtainable,  may 
be  found  in  the  works  of  Cannone,'  Fassano,'-  and  Pinard.^ 

The  following  are  summaries  of  cases  of  torsion  of  the  Fallopian 
tubes  caused  by  non-gonococcal  lesions : 

Anspaili.  /)'.  M.  (.\iucr,  Ji.ur.  (H.st..  October,  1912,  p.  553). — Age,  twenty-six.  Symptoms 
siiiiiilaiiiii;  .nine  a  1 1|  leii.  lull  i>  (  »|  ier.it  ii  Ml  revealed  long,  retort-shaped  right  tube  con- 
taiiiiiii;  lilnoil  ami  jius,  twisled  2' 2  times  in  the  direction  of  the  hands  of  a  watch. 
Salpiiinn-dniihiirectomy.  Recovery.  Subsequent  to  operation  patient  complained  of 
pain  in  left  ovarian  region,  and  a  few  months  later  a  second  operation  showed  a  similar 
shai)eil  tube  on  the  left  side.  Microscopic  examination  proved  the  latter  to  be  tu- 
bercular in  origin.  The  orifiiii  of  the  infection  on  the  right  side  was  probably  similar, 
but  this  point  could  not  po^ilivejy  be  ileteniiined.  because  of  the  dense  infiltration  with 
blood  and  numerous  heiuorrhagic  infarcts  which  were  present.     Recovery. 

Awtray  (Arch.  Mens.  d'Obst.  et  de  Gyn.,  July,  1912). — A  girl  fourteen  years  of  age  pre- 
sented symptoms  which  were  diagnosed  as  appendicitis;  at  operation  the  tube  and 
ovary  were  found  to  be  twisted  tvnce  in  the  direction  of  the  hands  of  a  clock.  Salpingo- 
oophorectomy  was  performed  and  followed  by  recovery.  The  case  is  reported  as  one 
of  spontaneous  torsion  of  a  normal  tube  and  ovary. 

Chaput  (Rev.  de  Gyn.,  1906,  tome  x,  p.  963).— Case  ^.— Age,  twenty.  Never  men- 
struated. At  age  of  seventeen  symptoms  of  gynatresia  began.  Objective  symptoms: 
Abdomen  swollen,  resembling  myoma.  On  percussion,  clulness;  on  palpation,  the 
uterus  enlarged,  hard,  tender,  reached  to  about  umbilicus.     Lateral  mass  which  filled 

•  Cannone:   Anjou  Med.,  Angers,  1911,  vol.  xviii,  p.  1. 

°Fas,sano:  Delia  torsion  pedunculo  sacto.salpingi  morgagni,  Milan,  1909,  vol.  Ii,  [)t. 
1,  p.  ;?73. 

=  Pinard:    Compt.  rend.  .soc.  d'obstet.,  gyn.,  pa?d.,  Paris,  October,  1910. 


rNUSI\\L    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         355 

pelvis  and  iliac  fossa  attached  to  uterus.  Operation:  Puncture  of  hymen,  followed  by 
discharge  (IJ2  liters)  of  blackish  blood.  After  puncture  a  large  tumor  could  still  be 
felt  in  the  left  iliac  fossa.  Laparotomy  showed  a  large  hematosalpinx  on  the  right, 
twisted  6  times,  and  a  small  hematosalpinx  on  the  left,  twisted  5  times.  Operation: 
Bilateral  salpingo-oophorectomy.  Death. 
Case  2. — Age,  eighteen.  Xo  symptoms  until  sixteen,  then  symptoms  of  gynatresia  com- 
menced. Objective  findings:  Tumor  in  right  flank,  rising  to  umbilicus.  Operation: 
Vaginal  section.  Death.  Autopsy  showed  hematometra.  Right  tube,  hemato- 
salpinx, twisted  once,  including  mesovarium.  Opposite  adnexa,  similar  pathology, 
but  no  twists. 
Lomlon  Ohst.  Soc.  (London  Obst.  Soc.  Trans.,  1898,  vol.  xl,  p.  325).— The  president  of  the 
London  Obstetrical  Society,  during  the  discussion  of  Bland-Sutton's  paper  on  tubal 
pregnancy,  stated  that  he  had  met  a  case  in  which  the  mole  containing  tube  had 
become  twisted  on  its  axis,  with  results  similar  to  those  which  occur  when  the  pedicle 
of  a  small  ovarian  cyst  becomes  twisted. 

Marlin,  A.  (Zeit.  f.  Geb.  u.  Gyn.,  1903,  vol.  xxvi,  p.  221). — Age,  thirty-one.  V-para. 
Pain  in  lower  left  abdomen  for  two  weeks,  making  patient  unfit  for  work.  Mass  size 
of  two  fists  in  left  side  of  pelvis.  Right  adnexa  normal.  Diagnosis:  Left  tubal  preg- 
nancy, torsion  and  numerous  adhesions,  with  bloody  ascites.  Clinical  diagnosis  con- 
firmed by  microscope. 

McCann  (Lancet,  May  9,  1903). — Age,  thirty-four.  Curetage  in  1898  for  purulent  dis- 
charge; no  abnormality  of  adnexa  at  that  time.  Sudden  seizure  October,  1900. 
Similar  attacks  March,  April,  and  May,  1901.  Operation  June  15,  1901.  Right  tube 
the  seat  of  an  ectopic  pregnancy  and  twisted  three  times.  Right  ovary  and  opposite 
adnexa  were  normal. 

r.  Mcrderrnorl,  P.  (Xederl.  Tijdsch.  voor  verlosken  Gyn.,  p.  175;  abst.  in  Frommel's  Jahres- 
bcricht,  1905,  p.  209). — Age,  twenty-four.  Pain  in  lower  abdomen  for  five  years. 
At  operation  bilateral  suppurative  tubal  lesions  were  found;  the  right  side  was  twisted. 
Microscopically,  these  tubes  proved  to  be  of  tubercular  origin. 

Pozzi  (Compt.  rend,  de  la  soc.  d'obst.,  gyn".,  pa^d.,  Paris,  1900,  vol.  ii,  p.95). — Age,  thirty- 
three.  1-para  (forceps).  Subjective  conditions:  Metritis  at  age  of  twenty-eight; 
from  time  to  time  thereafter  attacks  of  pain  lasting  two  weeks,  not  at  menstrual  periods. 
January,  1900,  very  severe  pains  in  lower  abdomen.  From  then  on  several  attacks  of 
abdominal  pain  and  constant  bleeding  until  time  of  operation.  Objective  findings: 
Corvi-\  large,  sfift,  patulous.  I'terus  large;  to  left  and  in  front  of  uterus  a  cyst  size 
of  fetal  head:  on  right,  slight  induration.  Diagnosis  before  operation:  Ovarian  cyst, 
left:  salpingitis,  right.  Operation:  April  2,  1900.  Large  tumor  resembling  ovarian 
cyst  found  1111  left  side,  but  pedicle  arises  from  right  and  proves  to  be  an  enormously 
dilated  tul)e;  weighs  ',W()  grains,  twisted  once  reversely  to  hands  of  watch.  Ovary 
sclerocystic.  Contents  of  tube:  Fetus,  3J^  cm.;  dead,  not  macerated.  Opposite 
adnexa:  Ovary,  normal;  tube,  hydrosalpinx.     Salpingostomy.     Result,  cure. 

Ross  (.\mer.  Jour.  Obst.,  190(>,  vol.  liv,  p.  0.53). — Diagnosis  before  operation:  Acute  ap- 
pendicitis. Pain  began  after  cranking  motor  car.  Emergency  operation.  Bilateral 
salpingectomy.  Both  tubes  were  the  seat  of  suppurative  tubercular  lesions,  and  the 
right  was  twisted. 

Sampson,  J.  A.  (Amer.  Jour.  Obst.,  August,  1912,  p.  271). — Age,  twenty-one.  Sudden 
attack,  simulating  ovarian  cyst,  with  torsion.  Operation  showed  bilateral  pus- 
tubes,  with  torsion  on  the  right  side.  Supravaginal  hysterectomy;  bilateral  sal- 
pingectomy. Highl  oiipliorectomy.  Microscopically,  the  tube  proved  to  be  the  seat 
of  a  tubercular  infection. 

Slrogaiiojf  (Vratch,  1893,  p.  1095,  quoted  from  Praeger:  Arch.  f.  Ciyn.,  1899,  vol.  Iviii, 
p.  579). — Right  hydrohematosalpinx  and  cystic  ovary.  Miero.scopic  examination 
showed  the  tube  to  be  the  seat  of  an  adenosarcoma  twisted  twice. 

Warriek  (Rev.  .\imal.  de  Gyn.,  1894,  Xo.  41,  p.  335). — .Vge,  forty-three.  Ill-para.  Diag- 
nosis before  o|)eration:  Right  ovarian  cyst,  torsion.  Diagno.sis  after  operation: 
Right  tubo-ovarian  cyst,  twisted  1 '  2  times;  left  hydrosalpinx,  twisted  1)2  times. 
Microscopic  examination  .showed  both  tubes  to  be  the  seat  of  carcinoma. 

DIFFUSE  GONORRHEAL  PERITONITIS 
In  1880  Saiif^cr  reported  two  eases  of  puerperal   peritonitis  that 
were  probabl}-  of  gonorrheal  origin.     Between  1886  and  1891  Stevens, 


356  GONORRHEA    IN   WOMEN 

Loven,^  Penrose,-  Huber,^  and  Hatfield^  published  cases  in  which 
they  beheved  the  gonococcus  to  be  the  exciting  cause.  In  1891,  at 
the  meeting  of  the  German  Gynecological  Society  in  Bonn,  Wert- 
heim''  proved  conclusively,  as  a  result  of  carefully  conducted  ex- 
periments, that  the  gonococcus  may,  in  some  cases,  produce  a  general 
peritonitis.  Bumm  had  hitherto  doubted  the  existence  of  this  con- 
dition. Shortly  after  this  Wertheim  reported  a  case  of  general  peri- 
tonitis in  which  the  gonococci  were  recovered  from  the  peritoneal 
exudate  in  pure  culture.  Owing  to  the  rarity  of  diffuse  gonorrheal 
peritonitis  and  the  relative  frequency  of  general  infections  of  the  peri- 
toneum resulting  from  other  causes,  no  cases  should  be  considered 
authentic  unless  they  have  been  so  proved  by  a  careful  bacteriologic 
examination.  The  work  of  Gushing,^  Hunner,"  Wertheim,*  Goodman,' 
and  others  has  amply  demonstrated  that  the  gonococcus  may,  in  some 
instances,  produce  general  peritonitis.  That  this  is  a  rare  condition  is 
proved  by  the  fact  that  in  1907  Goodman'"  was  able  to  collect  only  75 
cases,  and  of  these,  only  30  had  been  confirmed  by  bacteriologic  exami- 
nation at  operation  or  autopsy.  Diffuse  gonorrheal  peritonitis  may 
occur  in  young  girls  before  pubertj^,  as  a  result  of  infection  of  the  ex 
ternal  genitalia  or  vagina,  as  shown  by  Comby"  (8  cases),  Northrup  (2 
cases),  Baginsky,^-  Mejia,''  Galvagno,^^  Dowd,'^  Koplik,'^Variot,"and 
Cumston'* ;  the  youngest  of  these  children  was  four  years  of  age,  and  the 
oldest,  twelve  years.  Comby's  8  cases  all  resulted  from  vulvovaginitis;  1 
was  mild  and  X  were  severe.  This  author  states  that  in  children  the 
onset  of  gonorrheal  peritonitis  is  extremely  sudden  and  acute.  Rol- 
leston''  believes  that  mild  cases  are  often  overlooked  or  not  recognized. 

1  Loven,  G.:  Hygeia,  1886.  •  Penrose:  Med.  News,  July  5,  1890. 

=  Huber,  F.:  Trans.  Amer.  Med.  Soc.,  1890,  vol.  vi. 
<  Hatfield,  M.  P.:  Arch.  Pediat.,  1886. 

'  Wertheim:    "Zur  Frage  von  der  Gonorrhoe,"  Verhandlungen  der  ileutschen  Gesell- 
schaft  f.  Gyn.,  IV.  Kongress,  1891,  p.  346. 

«  Gushing,  H.  W.:  Johns  Hopkins  Hospital  Bull.,  May,  1899,  p.  75. 

'  Hunner:  Johns  Hopkins  Hosp.  Bull.,  1899,  vol.  xiii,  p.  247. 

»  Wertheim:  Cent.  f.  Gyn.,  1892,  vol.  xvd,  p.  38.5. 

'  Goodman,  C.:  Amer.  Jour.  Dermat.,  October,  1911. 

">  Goodman,  C.:  Annales  Surg.,  1907,  vol.  xlvi,  No.  2,  p.  111. 

"  Comby,  J.:  Arch.  mal.  d.  Enfants,  1901,  vol.  iv,  p.  513. 

'^  Baginsky:  Lehrb.  der  Kinderkrankheiten,  1902. 

"Mejia:   Abst.  Cent.  f.  allgem.  Path.  u.  Path.-anat.,  1901,  vol.  \a. 

"  Galvagno,  P. :  Arch,  di  Pat.  e  clin.  infant,  1903,  vol.  ii,  Nos.  3  and  4,  p.  73. 

'*Dowd:   Annal.  Surg.,  February,  1912. 

"■Koplik:   Diseases  of  Infancy  and  Childhood,  3d  ed.,  p.  571. 

"  Variot:    Gaz.  des  hopitaux,  March  8,  1904. 

"  Cumston,  C.  G.:  Amer.  Med.  Jour.,  1904,  vol.  iv. 

"RoUeston:  Modern  Medicine,  Osier,  vol.  v,  p.  531. 


UNUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         357 

White'  thinks  that  one  of  the  reasons  for  the  rarity-  of  gonorrheal 
peritonitis  is  that  the  gonococci  flourish  best  at  a  temperature  of  from 
91°  to  98°  F.,  and  that  a  higher  temperature,  such  as  would  be  en- 
countered in  the  peritoneal   cavity,  inhibits  its  activity. 

TMien  the  normal  resistance  of  the  peritoneum  is  diminished,  a  gon- 
orrheal peritonitis  is  more  likely  to  occur.  The  infection  of  the  perito- 
neum not  infreciuently  follows  a  menstrual  period  and  the  puerperium. 
The  disease  is  much  more  frequent  in  women  than  in  men,  because  of 
the  anatomic  location  of  the  organs  usually  affected  by  the  gonococcus. 
Gonorrheal  peritonitis  may  be  produced  bj^  the  leakage  of  a  pus-tube,  by 
the  torsion  or  rupture  of  an  inflamed  tube,  or  it  may  follow  an  opera- 
tion performed  for  pelvic  inflammatory  disease.  In  rare  instances 
cases  ha^-e  been  recorded  in  which  the  infection  has  been  conveyed 
through  the  lym])hatic  system.  The  anatomic  lesions  produced  by 
gonorrheal  peritonitis  are  usually  slight  as  compared  to  other  forms 
of  infection  in  the  peritoneal  cavit}'.  There  is  generally  a  uniform 
injection  of  the  peritoneum,  which  is  moderateh'  dry.  The  peritoneal 
cavit}^,  as  a  rule,  contains  but  little  pus.  It  is  partly  due  to  this 
viscid  character  of  the  exudate,  which  quicklj^  produces  adhesion  and 
thus  tends  to  confine  the  disease  to  the  pelvis,  that  general  peritonitis 
of  gonorrheal  origin  is  so  seldom  encountered. 

Symptoms. — The  sj-mptoms  are  those  of  general  peritonitis,  but 
they  are  usually  moderately  mild.  They  generally  appear  suddenly 
and  are  severe  for  the  first  day  or  two,  after  which  time,  in  favorable 
cases,  they  gradually  subside,  the  entire  attack  varying  in  duration 
from  a  few  days  to  a  week  or  more.  Usually  the  physical  evidences 
of  peritonitis  are  most  marked  over  the  lower  abdomen.  The  disease 
in  more  fatal  in  children  than  in  adults.  The  mortality  among  the 
former  has  been  estimated  at  20  per  cent,  by  Galvagno.-  Among  the 
30  cases  of  diffuse  gonorrheal  peritonitis  collected  by  Goodman,^  and 
which  were  confirmed  b\'  bacteriologic  examination,  14  deaths  resulted. 
Twenty  were  operated  upon,  with  a  mortalitj'  of  20  per  cent.  Two  of 
these  deaths  cannot  be  ascribed  to  the  operation  nor  to  the  gonorrheal 
peritonitis  alone,  as  one  case  developed  bronchopneumonia,  and  at 
autopsy,  while  gonococci  were  recovered  from  the  peritoneal  cavity, 
streptococci  were  found  in  the  blood  of  the  heart  and  other  organs. 
The  second  case  suffered  from  a  severe  empyema.  If  these  2  cases 
are  excluded,  the  mortalitj'  is  reduced  to  11  per  cent,  for  the  18  cases 

'  White:  System  of  Medicine,  .-Mlljutt  mid  Hollcston,  lOO.'j,  vol.  i,  p.  S.i,"). 
'  Galvagno:  .-Vrch.  di  Patolog.  e  elin.  infant,  1904,  vol.  ii,  Xos.  3  and  4,  p.  73. 
'Goodman,  C.:  Amer.  .Surg.,  1907,  vol.  xlvi,  No.  2,  ji.  111. 


358  GONORRHEA    IN    WOMEN 

subjected  to  operative  intervention.  Albrecht'  reports  4  cases  of 
gonorrheal  peritonitis,  all  of  which  recovered.  In  2,  operation  was 
performed.  In  each  case  the  onset  was  sudden  and  moderately  severe. 
Subsidence  of  symptoms  occurred  in  less  time  than  if  the  infection 
had  been  caused  by  the  ordinary  pyogenic  organisms.  This  writer 
agrees  with  Doderlein  that  a  good  prognosis  may  be  made  in  gonorrheal 
peritonitis. 

Grekow-  records  the  histories  of  2  remarkable  cases  of  motor 
gastric  insufficiency  which  he  believes  to  have  been  of  gonorrheal 
origin.  Perigastritis,  evidently  the  result  of  an  old  general  gonorrheal 
peritonitis,  was  present,  and  resulted  in  spasm  of  the  pylorus  or 
hypertrophy  and  dilatation  of  the  stomach.  This  observer  states 
that  the  pylorus  may  become  occluded  by  adhesions  from  without, 
or  by  a  reflex  spastic  constriction.  In  either  case  the  stomach  shows 
evidences  of  great  motor  insufficiency,  with  hypertrophy  of  the  pylorus 
and  adhesions  in  its  vicinity.  Both  the  recorded  cases  occurred  in 
females,  one  eighteen  and  the  other  twenty-two  years  of  age. 

The  following  is  the  report  of  2  hitherto  unpublished  cases  of  diffuse 
gonorrheal  peritonitis  occurring  in  the  Gynecologic  Department  of 
the  University  of  Pennsylvania  Hospital: 

Case  1. — Colored  woman,  twenty-seven  years  of  age.  The  patient 
gave  a  history  of  pelvic  inflammatory  disease  of  two  months'  duration. 
Pelvic  examination  revealed  evidences  of  gonorrhea  in  the  external 
genitalia  and  bilateral  inflammatory  adnexal  lesions.  At  operation 
the  peritoneal  cavity  was  carefully  walled  off  by  gauze.  During  the 
course  of  a  right  salpingo-oophorectomy  and  left  salpingectomy  about 
a  teaspoonful  of  pus  was  discharged  from  the  right  tube  into  the 
peritoneal  cavity.  Both  appendages  were  densely  adherent.  On  the 
third  day  following  the  operation  the  patient  gradually  developed 
symptoms  of  general  peritonitis.  The  temperature  never  rose  above 
102.2°  F.,  or  the  pulse  above  130.  The  abdomen  was  again  opened, 
flushed  with  normal  salt  solution,  and  gauze  drainage  inserted.  Cul- 
tures at  this  time  showed  the  peritoneal  exudate  to  contain  gonococci 
in  pure  culture.  But  little  free  fluid  was  present.  Convalescence 
was  normal. 

Case  2. — White  woman,  thirty  years  of  age.  This  patient  gave  a 
history  of  pain  in  the  lower  abdomen,  dysmenorrhea,  dyspareunia, 
and  irregular  and  profuse  menstruation.  Exacerbations,  during  which 
the  symptoms  of  pelvic  peritonitis  were  present,  had  occurred  a  number 
of  times.  During  the  last  of  these  attacks  the  symptoms  became 
more  severe,  and  evidences  of  general  peritonitis  developed,  and  on 
the  second  day  of  the  attack  the  patient  was  admitted  to  the  hospital. 

'  Albrecht,  H.:  Munch,  mod.  Woch.,  October  1.5,  1912,  p.  226.S. 

2  Grekow,  I.  I.:  Zent.  f.  Chir.,  Leipzig,  January  27,  1912,  vol.  x.wix,  No.  4,  p.  10.5. 


UNUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         359 

At  this  time  the  abdomen  was  distended  and  tender.  Her  temperature 
was  102°  F. ;  pulse,  126;  respirations,  24.  Nausea  and  vomiting 
were  present.  Evidences  of  gonorrhea  were  found  in  the  external 
genitalia.  At  operation  bilateral  pus-tubes  were  found.  The  peri- 
toneum was  reddened  and  the  intestines  were  distended.  Numerous 
light  adhesions,  especially  in  the  lower  abdomen,  were  observed. 
The  appendix  was  normal.  Bilateral  salpingectomy  and  right  oopho- 
rectomy were  performed.  Smears  from  various  portions  of  the 
peritoneal  cavity  showed  the  presence  of  numerous  diplococci,  which 
corresponded  in  staining  reaction  and  morphologj'  to  gonococci. 
Irrigation  with  normal  salt  solution.     Gauze  drainage.     Recover}^ 

Diagnosis. — The  diagnosis  of  peritonitis  usually  presents  no  great 
difficulty.  On  the  other  hand,  positive  proof  that  the  gonococcus  is 
the  etiologic  factor  cannot  be  obtained  without  a  bacteriologic  ex- 
amination of  the  peritoneal  exudate,  which  is,  of  course,  impossible 
until  the  abdomen  is  opened.  Under  certain  conditions,  however, 
the  gonorrheal  origin  should  be  strongly  suspected.  Summarized 
briefly,  these  are  the  presence  of  gonorrhea  in  the  genital  tract  and 
the  absence  of  other  causative  agents.  The  abrupt  onset  is  also 
somewhat  suggestive.  (Jomby^  states,  regarding  children,  that  the 
onset  of  gonococcal  peritonitis  is  absolutely  "unforeseen  and  brutal." 
The  degree  of  pain  varies  greatly  in  different  cases.  The  symptoms 
are  usually  most  marked  in  the  lower  abdomen.  The  temperature 
in  adults  usually  denotes  a  somewhat  milder  grade  of  infection  than 
is  generally  encountered  in  diffuse  peritonitis  of  pyogenic  origin.  In 
neither  of  Cushing's-  cases  was  the  temperature  above  100.5°  F.  In 
children  the  hyperpyrexia  is  often  pronounced,  the  temperature  not 
infrequently  reaching  104°  F.  and  the  pulse  140  to  160.  Brose,' 
Cashing,'  and  others  have  remarked  upon  the  peculiar  dry,  fibrinous 
character  of  the  peritonitis  jiroduced  by  the  gonococcus.  In  their 
cases  there  was  j^ractically  no  free  fluid  in  the  peritoneal  cavity.  These 
jioints,  combined  with  palpable  tubal  lesions,  should  lead  to  a  correct 
diagnosis  in  the  majority  of  instances.  In  children,  the  presence  of  a 
vulvovaginitis  should  lead  to  the  consideration  of  this  type  of  in- 
fection, and  on  account  of  the  frequency  of  gonorrheal  peritonitis  in 
the  young,  the  vagina  should  always  be  examined  in  cases  iM'csenting 
symptoms  of  i^erilonitis. 

Treatment,  'i'lic  approijriatc  treatment  will  vary  with  liic  in- 
dividual case.     M  the  present  time  the  general  tendency,  in  all  acute 

'Coml)y,  ,1.:  Anii.  inal.  d.  Kiinmls,  lOOl,  vol.  iv,  p.  .51:5. 
UJu-shing,  H.  W.:   .Johns  Iloplvins  Mosp.  Hull.,  Mi.y,  ISW,  p.  7.5. 
'  Brosc,  I'.:    Hcrlln.  kliii.  Woclicnsclir.,  ISDli,  vol.  xxxili,  p.  779. 
'CiLsliiiiK,  H.  W.:  Johns  Hopkins  IIosp.  Hull.,  May,  IS'.m,  p.  7.5. 


360  GONORRHEA   IN   WOMEN 

gonorrheal  conditions,  is  to  delay  operative  intervention,  when  this 
can  be  done  with  safety.  The  surgeon  must,  therefore,  be  guided 
entirely  by  the  severity  of  the  symptoms.  One  of  the  greatest  dif- 
ficulties in  these  cases  is  to  determine  before  operation  the  type  of 
infection  that  is  present.  That  a  definite  proportion  of  cases  of  difTuse 
gonorrheal  peritonitis  recover  without  operative  interference  has  been 
amply  proved.  On  the  other  hand,  the  dangers  of  non-operative 
treatment  are  many.  Diffuse  gonorrheal  peritonitis  has  not  in- 
frequently been  mistaken  for  appendicitis,  and  the  reverse  is  quite 
possible.  Operative  intervention  in  the  series  of  18  cases  previously 
mentioned  resulted  in  only  2  deaths — certainly  not  a  high  mor- 
tality. Without  operation,  many  women  become  sterile  and  develop 
pelvic  lesions  that,  if  not  subsequently  relieved  surgically,  produce 
chronic  invalidism.  In  a  large  proportion  of  cases  the  waiting  policy 
merely  means  delay  in  operation.  If  the  symptoms  are  such  as  to 
permit  delay  without  danger  to  the  patient,  the  subsequent  operation 
can  often  be  performed  under  much  more  favorable  conditions,  and 
with  a  mortality  considerably  below  11  per  cent.  If  delay  is  decided 
upon,  in  the  interval  prior  to  operation  the  patient  should  be  placed 
in  the  upright  Fowler  position,  and  physiologic  normal  salt  solution 
introduced  into  the  rectum  by  the  Murphy  enteroclysis  method. 
At  the  same  time  the  treatment  appropriate  for  general  peritonitis 
should  be  instituted.  Koltz'  calls  attention  to  the  vascular  paralysis, 
especially  in  the  splanchnic  region,  which  is  attendant  upon  general 
peritonitis,  and'  the  heart  failure  which  is  secondary  to  this  condition. 
The  fall  in  blood-pressure  and  paralytic  ileus  and  ischuria,  which  so 
frequently  occur,  Koltz-  believes  call  for  the  exhibition  of  pituitrin. 
He  reports  20  cases  of  general  peritonitis  treated  with  this  preparation, 
with  good  results. 

Fvu'ther  references  to  diffuse  gonorrheal  peritonitis  may  be  found 
under  the  heading  of  Rupture  and  Torsion  of  Inflammatory  Uterine 
Adnexa. 

HYDROPS  TUBJE  PROFLUENS 
According  to  Findley,'*  probably  the  first  recorded  case  of  this 
condition  was  reported  by  Scanzoni,''  who  described  a  postmortem 
specimen  in  which  one  tube  was  found  distended  with  serum  and  the 
other  collapsed.  That  true  cases  of  intermittent  hydrosalpinx  are 
unusual  is  proved  by  Martin,*  who  found  but  8  cases  occurring  in  a 

'  Koltz:  Miinch.  med.  Woch.,  September  17,  1912.  -  Koltz:  Loc.  cil. 

3  Findley:  Amer.  Jour.  Ob.st.,  1906,  vol.  liii,  p.  23(i. 

*  Scanzoni:   Krankh.  d.  weibl.  Sexual-Organe,  fourth  ed.,  vol.  ii,  p.  7.5. 

5  Martin:  Krankheiten  der  Eileiter. 


UNUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         361 

series  of  1700  cases  of  salpingitis.  The  records  of  the  Gynecologic 
Department  of  the  University  show  but  3  cases  occurring  in  a  series  of 
925  inflammatoiy  tubes,  141  of  which  were  cases  of  hydrosalpinx. 

Etiology. — Hydrops  tubse  profluens  is  due  to  a  permanent  closure 
of  the  outer  and  a  temporary  occlusion  of  the  inner  end  of  the  tube. 
The  latter  may  be  caused  by  an  inflammatory  swelling  of  the  mucosa 
or  kinking  of  the  tube.  The  secretions  of  the  tube  are  thus  retained 
until  the  inflammation  of  the  proximal  end  of  the  ov^iduct  subsides 
sufficientl}'  to  allow  the  escape  of  the  fluid  into  the  uterus,  or  until 
the  intratubal  tension  is  sufficient  to  overcome  the  obstruction,  when 
the  kink  straightens  out — much  in  the  manner  of  the  ordinary  garden 
hose — and  allows  the  tube  to  evacuate  itself.  The  frequency  with 
which  the  tube  empties  itself  varies  gi-eath'  in  different  cases.  Frank 
describes  a  case  in  which,  for  a  period  of  six  months,  half  a  liter  of 
fluid  was  discharged  daily  through  the  uterus.  Our  own  cases  also 
vary  in  this  respect.  In  one  case  the  condition  had  apparently  been 
present  for  nearly  two  years,  the  escape  of  fluid  occurring  every  four 
to  eight  weeks.  In  another  case  the  tube  evacuated  itself  much  more 
frequentlj',  although  at  irregular  intervals.  Bland-Sutton  doubts  the 
occurrence  of  this  condition,  believing  that,  in  many  of  the  cases, 
the  fluid  has  its  origin  in  the  uterus.  That  the  condition  does,  how- 
ever, occur  has  been  amplyprovcd  by  the  reports  of  Hennig,'  Schramm,- 
Martin,''  Doran,^  and  many  others.  Hydrops  tuba?  profluens  should 
not  be  considered  as  a  pathologic  entity,  but  rather  as  a  variety  of 
hydrosalpinx.  There  seems  to  be  no  doubt  that  some  of  these  cases 
may  undergo  a  spontaneous  cure  and  that  in  other  instances  the  uterine 
end  of  the  tube  maj'  be  intermittently  patulous  for  a  time  and  then 
become  permanently  occluded. 

Symptoms. — These  are  similar  to  those  seen  in  an  ordinary  case 
of  hydrosali)inx,  except  that  in  this  variety  of  lesion  there  is  an  inter- 
mittent discharge  of  fluid  through  the  uterus,  which  is  almost  in- 
variably followed  by  temporary  relief  of  symptoms.  Bimanual  ex- 
amination at  this  time  will  reveal  the  tube  collapsed,  while  at  a  prior 
or  later  period  a  fluctuant,  elastic  tiuiior  will  l)e  present. 

GONORRHEAL  INFECTION  OF  INTRAPELVIC  NEOPLASMS 
IntraiM-ritoncal   goiiorrhoa   shows    a   marked  predilection   for    the 
pelvis,  and  only  in  rare    instances  does  a  general   infection  of  the 
peritoneum  result.     A  very  unusual  complication  is  that  described  by 

'  Hennig:  Tubenkrankh.,  Leipzig,  1870. 

'Schramm:  .Arch.  f.  Gyn.,  voL  xxxix,  p.  17.  'Martin:   Kranklinitpn  cicr  Eileifor. 

'  Doran,  A.:  •Sy.stcin  of  Gynecology,  vol.  xxxix,  |).  17. 


362  GONORRHEA    IN    WOMEN 

Brettauer/  who  reports  a  case  in  which  a  gonorrheal  infection  took 
place  in  a  large  unilocular  ovarian  cyst.  The  nucroorganisms  were 
recovered  from  the  distal  end  of  the  Fallopian  tube,  from  the  uterine 
cavity,  and  from  the  contents  of  the  cyst.  Following  removal  of  the 
cyst  the  patient  made  a  normal  recovery.  Confrontation  in  this  case 
proved  that  the  patient's  husband  was  suffering  from  an  acute  attack 
of  urethritis.  Repeated  efforts,  both  before  and  after  operation,  to 
demonstrate  the  presence  of  the  gonococcus  failed  to  reveal  the  specific 
microorganism  in  the  external  genitalia  of  the  wife,  and  while  at 
operation  the  organisms  were  recovered  from  the  Fallopian  tube, 
macroscopically  the  latter  organ  was  normal.  Clinically,  this  case 
presented  symptoms  not  unlike  those  produced  by  torsion. 

MIXED  INFECTION 

A  mixed  infection,  i.  e.,  gonococci  and  other  organisms,  such  as 
the  tubercle  bacilli,  is  by  no  means  uncommon.  It  is  impossible,  in 
many  cases,  to  determine  whether  the  gonorrheal  condition  is  super- 
imposed upon  the  tuberculous  or  if  the  reverse  is  the  case.  Most 
authorities,  however,  believe  that  the  latter  is  the  more  frequent  condi- 
tion, and  that  once  the  tubal  mucosa  is  altered  by  a  gonorrheal  inflam- 
mation an  excellent  soil  for  the  development  of  the  secondary  infections 
is  prepared.  In  the  Pathologic  Laboratory  of  the  University  of  Penn- 
sylvania 31  cases  of  tuberculosis  of  the  tubes  have  been  examined  by  the 
author.  In  20.  of  these  the  histories  seemed  to  cover  this  point ;  6  of 
these  have  apparentlj^  been  associated  with  clinical  evidences  of  gonor- 
rhea. Owing  to  the  fact  that  bacteriologic  tests  have  not  been  performed 
upon  the  majority  of  these  cases,  it  is  impossible  definitely  to  determine 
this  point.  The  possibility  of  tuberculosis  accompanying  gonorrheal 
lesions  of  the  adnexa  should  be  weighed,  and  due  precautions  taken 
in  making  the  prognosis  and  in  instituting  treatment  in  such  cases. 

Cultures  taken  from  cases  of  gonorrhea  early  in  the  acute  stage 
usually  show  an  unmixed  infection,  but  when  the  disease  becomes 
chronic  and  has  been  of  long  standing,  mixed  or,  as  Menge  properly 
terms  them,  secondary  infections,  are  frequently  encountered.  This 
point  is  of  importance  when  employing  the  vaccine  or  serum  treatment. 
Gonorrheal  lesions  of  the  adnexa  often  contain  colon  bacilli  or  other 
organisms.  It  seems  probable  that  the  gonococcus  not  infrequently 
prepares  the  soil  for  the  streptococcus  or  other  pyogenic  organisms. 

'  Brettauer:  Amer.  ,Jour.  Obst,,  190S,  vol.  Ivii,  p.  411. 


UNUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         363 

GCNCRKHEA  AS  THE  ETIOLOGIC  FACTOR  IN  THE  CAUSATION  OF  ECTOPIC 
PREGNANCY 

The  fact  that  inflammation  of  the  oviducts  is  often  a  forerunner 
of  tubal  pregnancy,  and  that  salpingitis  is  one  of  the  most  freciuent 
causative  agents  in  the  production  of  tubal  gestation,  is  now  generally 
appreciated.  Fehling^  reports  the  results  obtained  in  170  cases  of 
early  extra-uterine  pregnancy,  in  nearly  half  of  which,  when  a  careful 
examination  was  possible,  the  opposite  adnexa  were  found  diseased. 
He  also  states  that  in  54  of  143  cases  the  lesions  were  so  extensive  as 
to  make  a  bilateral  salpingectomy  necessarj-.  This  observer  dwells 
strongly  upon  gonorrhea  as  a  predisposing  factor  in  the  production  of 
tubal  pregnancy. 

Cones'  states  that  an  analysis  of  202  cases  of  extra-uterine  preg- 
nancy occurring  in  the  Massachusetts  General  Hospital  showed  that 
over  88  per  cent,  of  these  cases  were  accompanied  by  inflammatory 
lesions  of  the  tubes  or  ovaries.  Meyer^  found  that  in  a  series  of  44 
cases  of  tubal  pregnancy  more  than  33  per  cent,  gave  an  antecedent 
history  of  gonorrhea.  During  the  past  twelve  years  64  cases  of  tubal 
pregnancy  have  been  operated  upon  in  the  Gynecologic  Department 
of  the  University  Hospital.  Of  these,  18  were  in  all  probability  as- 
sociated with  or  preceded  by  gonorrhea.  Twenty  additional  cases 
presented  pelvic  lesions  which,  upon  histologic  examination,  strongly 
suggested  the  presence  of  a  gonorrheal  infection. 

GONORRHEA  AS  A  PREDISPOSING  FACTOR  TO  CARCINOMA 
Primary  carcinoma  of  the  l'"alloi)ian  tube  is  a  rare  disease.  Until 
1909  only  about  86  authentic  cases  of  this  condition  were  on  record.^ 
Pathologists  generally  agree  that  inflammation  is  a  predisposing  factor 
to  the  production  of  carcinoma  of  the  tube.  The  4  cases  which  the 
author  has  had  the  oj)portunity  of  examining  all  showed  positive 
evidence  of  preexisting  inflammation.  Rossinsky^  has  recently  re- 
ported in  detail  a  case  of  primary  carcinoma  of  the  tube  which  he 
attributes  to  a  previous  gonoi-rhea.  The  tumor  developed  on  the  site 
of  an  old  salpingitis.  The  relation  which  a  preexisting  endometritis 
may  bear  to  the  subsequent  development  of  carcinoma  is  undetermined. 
Cullcn'"'  states  that   he  has  (>xaniiiic(l  llic  mucosa  in   Id  cases  of  car- 

'  iM'hlini;;,  II.:   Arch.  f.  (lyii..  vol.  xcii,  .No.  I, 

=  Cones  \V.  P.:   Ho.iloii  Mcil.  miil  Surn.  .lour.,  I!M  I.  vol.  clxiv,  p.  ti77. 

'  .Mcypr,  F.:  .Au.stnilian  Mc<l.  .lour.,  lM-l)ru:iry  17,  I'.U'J. 

'  Norris,  C.  C:  Surg.,  Gyn.,  and  Ohst.,  .\Iiircli,  IDO'.l,  p.  272. 

^  Uo.><sinsky,  T. :  Inaug.  Dissert.,  Ha.scI,  lillO. 

'•('iillcn,  T.  A.:  CunriT  of  tlic  rtcnis.  KKH),  p.  H.VJ.  1 ).  Applfton  .V  ( 'o..  N.  V. 


364  GONORRHEA    IN    WOMEN 

cinoma  of  the  body  of  the  uterus,  and  found  onlj'  2  in  which  there 
were  any  definite  evidences  of  endometritis.  He  adds,  however, 
that  from  the  study  of  the  material  at  his  disposal  he  has  not  been 
able  to  arrive  at  any  definite  conclusion  regarding  this  point.  Theil- 
haber^  believes  that  chronic  gonorrheal  inflammation  of  large  areas 
in  the  uterine  mucosa  and  adnexa  are  predisposing  factors  to  the  de- 
velopment of  carcinoma,  causing  interference  with  the  nutrition  of  the 
parts,  as  well  as  by  the  direct  irritant  action  of  the  discharges. 

HERNIATED  INFLAMMATORY  ADNEXA 
The  fact  that  a  tube  or  ovary  is  the  seat  of  an  inflammation  tends 
to  prevent  it  from  prolapsing  into  a  hernial  sac,  the  adhesions 
usually  holding  it  in  position.  Cullen-  has,  however,  recorded  a  case 
in  which  the  left  tube  and  ovary  were  removed  for  adnexitis.  Later 
the  patient  developed  an  appendiceal  abscess,  which  it  was  necessary 
to  drain.  A  hernia  developed  in  the  appendectomy  wound.  At  a  sub- 
sequent date  a  tender  mass  could  be  palpated  in  the  hernial  sac.  At 
operation  this  proved  to  be  a  hydrosalpinx  and  an  adherent  ovary. 
GoepeP  has  reported  a  case  in  which  a  pyosalpinx  was  found.  From 
the  description,  however,  it  would  appear  that  this  specimen  might 
quite  readily  have  been  a  hydrosalpinx  in  which,  as  a  result  of  inter- 
ference with  the  blood-supply  incident  to  location  within  the  hernial 
sac,  suppuration  had  occurred.  Le  Nouene^  has  also  recorded  the 
history  of  a  casp  in  which  a  hernia  contained  both  tubes  and  ovaries, 
the  adnexa  on  the  left  side  being  the  seat  of  a  suppurative  lesion.  In 
none  of  the  cases  just  described  is  the  type  of  infection  recorded. 

ESTHIOMENE  AND  ELEPHANTIASIS 

In  1903  Szasz^  reported  the  history  of  a  remarkable  case  of 
elephantiasis  of  the  external  genitalia  which  was  apparently  secondary 
to  or  developed  upon  the  site  of  a  preexisting  gonorrhea.  A  rectal 
stricture  and  gonorrheal  proctitis  were  present.  On  microscopic 
examination  the  labia  presented  a  typical  picture  of  elephantiasis. 
The  secondary  characteristics  were  manifest  in  the  enormously 
dilated  lymph-vessels.  Sections  from  the  peripheral  portions  con- 
tained small  cysts  that  could  be  seen  with  the  naked  eye.  These 
contained  clear  lymph.     The  cysts  were  lined  by  a  simple  layer  of 

'  Theilhaber:  Arch.  f.  Gyn.,  Berlin,  1912,  vol,  xcvi,  No.  3. 
=  Cullen:  T.  S.:  Johns  Hopkins  Hosp.  Bull.,  May,  1906,  p.  152. 
'  Goepel:  Zentralbl.  f.  Chir.,  1896,  vol.  x.\iii. 
'  Le  Nouene:  Gaz.  de  Gyn.,  190.3,  vol.  xv,  p.  337. 

'  Szasz:  Monats.  f.  Geb.  u.  Gyn.,  1903,  p.  999. 


Fig.  30. — Carcinoma  Which  Occurred  in  the  Fallopian  Tube  of  a  YorxG  Woman. 
riie  cureinoma  has  been  implanted  upon  a  preexisting  inflammatory  lesion.     The  cross-section  of  the  tube 
shows  the  papillan,'  character  of  the  carcinoma.     The  left  tube  is  the  seat  of  a  pyosalpinx.     Both  ovaries  show 
cystic  change  and  numerous  adhesions.     (For  f\ill  report  of  this  case  see  Surgery,  Gynecology,  and  Obstetrics, 
March.  UtOy.) 


«^«* 


Fi<:.  :i7. — C'aiu  iM>MA  OF  THE  Fai.loi'Ian  Tvue  (High  and  Low  Tuwho. 
rti<-  riiiihice  .shows  adhesiuns.     Th<-  inUHriihiriH  ih  ftomowhat  thickened  and  HbrouH.  and  itt  t«onie  pointr*  i.> 
infiltrated  with  groiipti  of  carcinomatous  cell«.     KvidcnccH  of  pret'xiHting  inflnnunalion.  characterlrcd  by  chronii 
inflnniMialory  exufhitc  and  nunierou.**  phicina-cellw.  are  everywhere  prewnt.     The  high  power  Hhows  the  UNiia 
charnpterij.ii(>  of  carHnoma  (Sure,  flyn.,  and  (iU^l..  March,  IIHUH. 


rXUSUAL    MANIFESTATIONS    AND    REMOTE    COMPLICATIONS         365 

endothelium.  Stein  and  Heilmann^  record  the  history  of  a  case  of 
esthiomene  of  the  external  genitalia  that  seems  to  have  been  secondary 
to  gonorrhea.  Over  both  labia,  but  most  marked  on  the  right  side, 
and  about  the  anus  were  numerous  macules,  papules,  and  cysts,  vary- 
ing in  size  from  that  of  a  pin-head  to  a  kidney-bean.  These  were 
isolated  or  grouped,  and  those  that  were  cystic  contained  a  limpid 
alkahne  fluid.  Here  and  there  superficial  ulcerations  were  present. 
The  condition  was  chronic,  and  the  tumors  were  not  sensitive.  The 
patient  had  a  rectal  stricture.  The  authors  state  that  they  found 
the  causal  factor  to  be,  in  the  first  place,  the  chemical  irritation 
of  the  discharge  from  the  rectum,  and,  in  the  second  place,  the 
rectal  stricture,  both  presumably  due  to  an  earlier  rectal  gonorrhea. 
On  purely  mechanical  grounds  the  lymphatic  stasis  would  account 
for  all  cUnical  and  pathologic  features  of  the  case  except  the  original 
ulceration. 

'  Stein,  A.,  and  Heilmann,  W.  J.:  Surg.,  Gyn.,  and  Obst.,  April,  1912,  p.  345. 


CHAPTER  XV 
GONORRHEA  IN  PREGNANCY,  LABOR,  AND  THE  PUERPERIUM 

As  has  been  mentioned  in  a  previous  chapter,  gonorrhea  is  a  fre- 
quent cause  of  steriUty.  Sterihty  may  be  produced  in  the  woman 
by  gonorrheal  lesions  of  the  external  genitalia  or  vagina,  which  cause 
severe  dyspareunia,  by  gonorrheal  cervicitis  or  endometritis,  or  by 
affections  of  the  tubes  or  ovaries.  If  the  tubes  are  occluded  or  the 
ovaries  are  so  diseased  that  follicles  cannot  mature  or  rupture,  con- 
ception is,  of  course,  impossible,  but  with  these  exceptions  pregnancy 
may  occur  in  the  female  gonorrheic.  Under  such  circumstances 
pregnancy  may  be  interrupted  as  a  result  of  the  direct  action  of  a 
decidual  endometritis  or  other  intrapelvic  lesions,  or  the  gestation 
may  proceed  to  term.  The  gonococcus  has  been  demonstrated  in 
the  decidua  by  Neumann, ^  Maslowsky,-  WiUiams,'  Kronig,^  and 
others  as  the  active  cause  of  inflammation  and  abortion  in  a  large 
series  of  cases.  Gonorrhea  may  precede  pregnancy  or  may  be  con- 
tracted during  gestation.  The  last  authority  was  the  first  definitely  to 
prove  the  existence  of  gonorrheal  deciduitis.  Kronig  cultivated  the 
gonococcus  from  9  cases,  all  of  which  presented  mild  clinical  symptoms. 
Cases  have  been  seen  in  which  a  woman  has  become  infected  with 
gonorrhea  at  the  time  conception  took  place.  Impregnation  seldom 
occurs  after  the  infection  has  extended  above  the  internal  os. 

The  influence  of  pregnancy  on  the  course  of  gonorrhea  is  usually 
quite  marked.  Pregnant  women  are,  as  a  result  of  the  increased 
blood-supply  of  the  genital  organs  and  the  softening  of  these  structures 
incident  to  gestation,  more  receptive  to  gonorrheal  infection  than  their 
non-gravid  sisters.  For  similar  reasons,  previously  latent  gonorrhea 
is  particularly  likely  to  become  active  during  the  course  of  gestation, 
and  extension  to  the  hitherto  normal  endometrium  and  appendages 
is  frequent.  Similar  histologic  and  anatomic  changes  occur,  but  to 
an  exaggerated  degree,  in  the  genital  tract  during  pregnancy  as  are 
found  during  menstruation,  a  period  when  extension  to  the  endome- 
trium and  adnexa  is  particularly  prone  to  take  place.    This  is  proved 

'  Neumann:   Monats.  f.  Geb.  u,  Gyn.,  April,  1896. 
-  Maslow.sky:  Ibid.,  1896,  vol.  iv,  No.  3. 
'  Williams,  J.  W.:  Amer.  Jour.  Obst.,  1899,  vol.  xxxix,  p.  289. 
'  Kronig:  Cent.  f.  Gyn.,  1893,  p.  157. 
366 


GONORRHEA    IX    PREGNANCY,    LABOR,    AND    THE    PVERPERIUM       367 

by  the  large  proportion  of  tubal  lesions  that  are  encountered  in  preg- 
nant women,  the  extension  in  many  of  these  necessarily  having 
occurred  after  conception,  as  the  oviducts  are  freriuently  found  oc- 
cluded. 

A  marked  amplification  of  the  symptoms  of  the  infection  are 
particularly  likely  to  occur  during  the  latter  months  of  pregnancy. 

Gonorrhea  is  extremeh'  frequent  during  pregnane}'.  C!urd'  iso- 
lated the  gonococcus  in  52  out  of  113  pregnant  women  applying  f(5r 
treatment  for  pelvic  pain  at  a  dispensary.  Leopold  -  estimated  that 
20  per  cent,  of  pregnant  women  had  gonorrhea.  Stephenson^  states 
that,  among  1101  pregnant  women,  the  gonococcus  was  demonstrable 
in  18.43  per  cent.  Fruhinsholz''  believes  that  gonococci  are  present 
in  from  20  to  25  per  cent,  of  pregnant  females.  Zwow'  found  gonococci 
in  75  of  130  pregnant  women.  Sanger, '^  Burckhardt,^  and  Lomer*  place 
the  figure  at  between  15  and  30  per  cent.  ]More  recent  observers, 
such  as  Taussig,''  Harrar,"*  and  others,  state  that  about  5  to  10  per 
cent,  of  parturient  women  have  gonorrhea.  The  latter  conservative 
estimate  is  probably  the  more  correct,  as  most  of  the  earlier  statistics 
are  based  only  upon  dispensary  patients,  a  class  of  women  in  whom 
gonorrhea  is  relatively  frec|uent. 

Further  studies  confirming  the  frequency  of  gonococci  as  the 
etiologic  factor  in  the  production  of  puerperal  infection  may  be  found 
in  the  works  of  Schottmiiller,"  Bund}','-  Goldschmidt.''*  and  many 
others. 

Symptoms. — These  differ  according  to  the  lesions  that  are  present, 
and  are  similar  to  those  seen  in  gonorrhea  in  the  non-pregnant  state, 
except  that  the  disease  is  likely  to  be  more  severe  and  progressive  in 
type.  Condylomata  especially  exhibit  active  growth,  and  if  these 
tumors  are  present,  their  large  size,  vascular  appearance,  and  rapid 
increase  in  bulk  are  fre(iuently  marked  features  of  the  case.  If  the 
infection  extends  to  the  endometrium,  abortion  may  occur.     Arthritis, 

1  (liird,  !•".  15.:   M(iiitrc;il  .Med.  .lour.,  I'JOS,  vol.  xxxvii,  p.  798. 

2  Leopold:  Arch.  f.  Clyn.,  1893,  vol.  xlvi,  p.  667. 

'  Stei)hpnson,  S.:  Oi)hthalmiu  NVonatoruni,  Loiulon,  1907,  |).  38. 

'  I'Vuhinsholz:  Ann.  dcClyn.,  October  and  Novenilicr,  19(1'-'. 

'  Zwow,  J.:  Hcv.  n6i)  d'ophlahnologie,  188S,  p.  I'S, 

"  Siiniicr:  Zeit.  f.  (iel).  ii.  Gyn.,  1880,  p.  177. 

'  Bmckhardt;   Beitriigc  z.  Geb.  u.  Gyn.,  1889,  vol.  ii,  p.  2. 

^  l.oiner:  Zclt.  f.  Gel),  u.  Gyn.,  1884,  vol.  x,  p.  :«•>. 

»  Taii.ssin:  .\nicr.  Ciyn.,  1903,  vol.  ii,  p.  334. 

'"  Harrar,  J.  A.:   Bull.  Lying-in  Mosp.,  New  York.  MmhIi,  I'tl  1,  p.  li'>0. 

"Scliottiniillcr:   Miinch.  med.  Woch.,  March  14,  1911. 

'-'  HuikIv:   Cent.  f.  Gyn.,  Feliniary  '.'.i,  1911. 

"  GoldschniidI:  Arch.  f.  (iyn.,  vol.  xeiii,  Xo.  -'. 


368  GONORRHEA   IN   WOMEN 

endocarditis,  general  peritonitis,  and  other  complications  are  more 
likely  to  take  place  than  if  pregnancy  were  not  present. 

Diagnosis. — The  diagnosis  of  gonorrhea  at  this  time  presents  no 
especial  difficulties,  and  the  same  methods  may  be  employed  as  have 
previously  been  described  in  an  earlier  chapter. 

Treatment  of  Gonorrhea  During  Pregnancy. — The  same  general 
principles  should  be  adopted  in  the  treatment  of  the  pregnant  gonor- 
rheic  as  are  followed  in  the  non-pregnant  patient.  Especial  care 
should  be  taken,  however,  to  prevent  the  extension  of  the  disease, 
and,  if  the  infection  is  confined  to  areas  below  the  internal  os,  entirely 
to  eradicate  the  gonorrhea  before  the  termination  of  pregnancy. 
With  this  end  in  view  an  active  and  systematic  course  of  treatment 
should  be  instituted.  Care  must  be  taken,  however,  to  avoid  in- 
ducing an  abortion.  For  this  reason  all  cervical  manipulations  and 
treatments  should  be  performed  with  the  greatest  gentleness  possible. 
The  introduction  of  powerful  antiseptics  far  into  the  cervical  canal, 
or  wide  dilatation  of  this  organ,  is  contraindicated  for  the  same  reason. 
The  maintenance  of  the  strictest  asepsis  is  necessary  in  the  treatment 
of  these  patients.  Examinations  should  be  gently  performed  and 
rest  and  the  absolute  interdiction  of  sexual  intercourse  and  all  forms 
of  violent  exercise  should  be  counseled.  Operative  procedures  are 
to  be  avoided  whenever  possible  on  account  of  the  dangers  of  prema- 
ture expulsion  of  the  fetus  and  the  possibility  of  spreading  the  in- 
fection. If  it  becomes  apparent  that  abortion  or  miscarriage  is 
inevitable,  then  such  prophylactic  measures  as  will  be  described  under 
the  Conduction  of  Labor  in  Gonorrheics  are  indicated. 

GONORRHEAL  PUERPERAL  INFECTION 
To  Kronig'  is  due  the  credit  for  having  been  the  first  to  adduce 
positive  bacteriologic  proof  of  the  pathologic  action  of  the  gonococci 
during  the  puerperium.  This  microorganism  plays  an  important 
part  in  the  production  of  puerperal  infection.  Sanger^  states  that 
even  under  the  most  favorable  circumstances,  15  per  cent,  of  women 
suffering  from  gonorrhea  at  the  time  of  delivery  develop  puerperal 
infection,  the  usual  type  of  lesion  being  an  inflammatory  condition 
of  the  adnexa.  Gurd^  and  others  are  of  the  opinion  that  the  gonococcus 
not  only  frequently  produces  infection  at  this  time,  but,  by  its  presence, 
is  a  strong  predisposing  factor  in  the  production  of  streptococcic  or 
other  form  of  sepsis.  The  normal  vaginal,  urethral,  and  cervical  epi- 
thelium is  not  often  attacked  by  the  ordinary  pyogenic  cocci.    When, 

'  Kronig:  Cent. f.  Gyn.,  1893,  p.  675.     ■  Sanger:  Centralbl.  f.  Geb.  u.  Gj-n.,  1886,  p.  177. 
2  Gurd,  F.  B.:  Montreal  Med.  Jour.,  1908,  vol.  xxxvii,  p.  798. 


GONORRHEA    IN    PREGNANCY,    LABOR,    AND    THE    PrERPERIUM       3(J9 

however,  the  resistance  of  these  parts  is  lessened  or  overcome  bj'  the 
gonococcus,  other  bacteria  seem  able  to  produce  their  characteristic 
lesions.  Gurd'  believes  that  this  accounts,  to  a  great  extent,  for  the 
diversity  of  opinion  held  bj^  various  authorities  upon  the  question  of 
auto-infection.  Among  14  cases  of  infection  following  abortion,  mis- 
carriage, or  labor,  Gurd'-  found  the  gonococcus  present  5  times  and 
4  times  associated  with  the  streptococcus.  Stephenson^  states  that  of 
354  cases  of  puerperal  infection,  14.763  per  cent,  were  due  to  the 
gonococcus.  Kronig^  demonstrated  the  gonococcus  in  50  out  of 
179  cases  of  puerperal  infection;  Taussig,^  in  17  per  cent.;  Vogel,® 
in  16  per  cent.;  Stone  and  McDonald,"  in  33  per  cent.;  Bumm,*  in 
7  per  cent.,  and  Williams,'  in  5  per  cent.  On  the  other  hand,  Foulerton 
and  Bonnej'"  believe  that  undue  prominence  has  been  given  to  the 
gonococcus  in  the  etiology  of  sepsis.  These  authors  examined  54 
ca.ses  of  puerperal  sepsis  without  finding  the  gonococcus. 

Symptoms. — These  may  arise  as  the  result  of  an  infection  with 
the  gonococcus  at  or  immediately  before  or  after  labor  in  a  previously 
healthy  woman,  the  microorganism  being  introduced  from  without, 
on  instruments  or  by  the  examining  hand,  or  more  frequently  it  maj^ 
result  from  an  extension  upward  of  a  cervical  gonorrhea  or  an  exacer- 
bation of  a  latent  endometritis  or  adnexitis.  Lea"  states  that  if  gonor- 
rhea of  the  external  genitalia  is  present,  exten.sion  to  the  endome- 
trium is  likely  to  occur  after  labor  or  abortion.  According  to  Kronig,'- 
Xatvig,"  and  Wegelius,'^  certain  varieties  of  microorganisms  from  the 
vulva  frequently  ascend  into  the  vagina  in  the  days  immediately 
subsequent  to  delivery.  Pilz'"'  and  Natvig'^  have  shown  that  these 
bacteria  are  usually  innocuous,  (ionorrheal  infection,  however, 
cannot  be  accounted  for  in  this  manner,  as  the  gonococcus  is  non- 
motile.  Infection  from  the  external  genitalia,  therefore,  occurs  only 
as  a  result  of  the  introduction  of  the  gonococcus  into  the  vagina  during 
the  manipulations  incident  to  the  care  of  the  patient.  In  mo.st  cases, 
however,  the  cervix  is  already  involved.     One  of  the  chief  character- 

'  (iiinl,  F.  B:   Montreal  Mcrl.  Jour.,  lOO"*,  vol.  .xxxvii,  p.  7i),S. 

'  (iiinl,  F.  B.:   Ibid.     '  Stephenson,  S.:  Ophthalmiii  Neonatorum,  London,  190H,  p.  38. 
'  Kronig:  Cent.  f.  Gyn.,  189.5,  p.  409.  '  Taurwig:  Ainer.  Gyn.,  l'.)():{,  vol.  ii,  p.  334. 

'  Vogel:  Zeit.scrhr.  f.  Gel>.  u.  Gyn.,  .Stuttgart,  1901,  vol.  xliv,  p.  412. 
'  .Stone  anil  McDonald:   .\iner.  .lour.  Oljst.,  1900,  vol.  liii,  p.  2.")1. 
■  Bunini:  Gent.  f.  Gyn.,  1.S99,  So.  11,  p.  '289. 
'  \Villiam.s  •'•  \\ '•:  .\nier.  .Jour.  Oli.st.,  1899,  vol.  xxxix,  p.  289. 

'"  Foulerton,  .\.  (j.  K  ,  and  Bonney.  V  :  Trans.  Obst.  Soc,  London,  190.'),  vol.  xlvii;  nUn 
Lancet,  London,  190.i,  vol   I,  !>.  ill.'i. 

"  Lea:   I'uerperal  Infection,  191  I.  '-  Kronig:  Cent.  f.  Gyn.,  189.'),  p.  409. 

"  Natvig:  Arch.  f.  Gyn.,  190."),  vol.  Ixxvi.  "  Wegeliu.s:   Arch.  f.  Gyn.,  vol.  Ixxxviii. 

"  Pilz:  .\rch.  f.  Gyn.,  vol.  Ixxii,  p.  .537.  "  Natvig:  Areh.  f.  (-!yn.,  190.5,  vol.  Ixxvi. 

24 


370  GONORRHEA    IN    WOMEN 

isties  of  a  pure  gonorrheal  puerperal  infection  is  the  lateness  of  the 
onset  of  the  symptoms.  The  period  of  incubation  in  the  uterus  or 
appendages  is  of  the  same  duration  as  in  other  portions  of  the  body; 
therefore,  as  a  result,  in  this  type  of  infection  definite  symptoms  rarely 
develop  before  the  third  day,  and  often  not  until  the  latter  part  of  the 
first  week — sometimes  even  later.  Occasionally,  when  the  infection  has 
extended  above  the  internal  os  before  the  onset  of  labor,  the  tempera- 
ture rises  shortly  after  delivery. 

The  lochia  is  foul  and  has  a  fetid,  musty  odor;  the  pulse  and 
temperature  range  somewhat  lower  and  the  patients  do  not  look  so 
ill  as  when  a  streptococcic  infection  is  present.  The  acute  symptoms 
usually  disappear  in  from  five  days  to  ten  days.  According  to 
Harrar,^  further  trouble  may  be  expected  in  12  per  cent,  of  such  cases. 
The  author  believes  that  this  percentage  should  be  at  least  doubled. 

Menge-  describes  a  form  of  late  puerperal  gonorrheal  endometritis 
that  occurs  between  the  sixth  and  seventeenth  week  of  the  puerperium, 
and  is  usually  coincident  with  the  first  menstruation  or  ovulation. 
The  earliest  manifestations  of  infection  are  often  malaise,  head- 
ache, and  a  slight  pyrexia.  Occasionally  nausea  or  vomiting  is 
present.  The  temperature  rarely  rises  above  101°  or  102.5°  F.  at 
any  stage  of  the  disease.  Indeed,  Bumm^  states  that  high  tempera- 
ture is  a  certain  indication  of  the  presence  of  microorganisms  other 
than  the  gonococcus.  Smith^  has,  however,  recorded  2  extremely 
severe  cases,  in  one  of  which  the  temperature  on  several  successive 
days  reached  107°  F.     Such  extremely  high  temperatures  are  very  rare. 

The  pulse-rate,  although  increased,  is  rarely  correspondingly  rapid, 
unless  as  the  result  of  the  weakness  incident  to  the  loss  of  blood. 
The  temperature  and  pulse  tend  to  run  an  even  course,  and  the  marked 
evening  rise  and  morning  remission,  so  characteristic  of  the  more 
virulent  forms  of  puerperal  infection,  are  absent.  The  coated  tongue, 
the  fetor  of  the  breath,  the  anorexia,  and  the  other  manifestations 
of  fever  are  usually  present.  The  urine  is  frequently  diminished  in 
amount,  of  high  specific  gravity,  and  often  contains  a  trace  of  albumin. 
The  bowels  are  usually  constipated,  but  diarrhea  may  be  present. 
If  the  infection  is  prolonged,  as  in  neglected  cases,  the  patient  loses 
flesh  and  strength,  and  the  various  functions  of  the  body  become  more 
or  less  impaired.  Pain  over  the  lower  abdomen  is  always  present. 
The  severity  of  the  symptoms  naturally  varies  with  the  individual 

'  Harrar,  J.  A.:  Bull.  Lying-in  Hosp.,  New  York,  March,  1911,  p.  166. 
-  Menge,  K.:  Handb.  der  Gesohlechtskrankheiten,  Vienna,  1910. 
'  Bumm:  Cent.  f.  Gyn.,  1899,  No.  11,  p.  289. 
■■  Smith,  ,T.  T.:  Cleveland  Med.  Jour.,  October,  1911,  p.  810. 


GONORRHEA    IX    PREGXAXCY,    LABOR,    AND    THE    PUERPEEIUM      371 

case,  but  are,  as  a  rule,  much  milder  than  in  the  streptococci  or  other 
varieties  of  puerperal  infection.  The  milk  secretion  is  usually  dim- 
inished, and  if  the  fever  is  high,  may  be  entirely  suppressed.  The 
lochia  becomes  purulent,  and  varies  in  color  from  a  yellowish-white 
to  a  deep  chocolate  color,  according  to  the  amount  of  admixture  of 
blood,  and  is  increased  in  quantity,  and  thick,  glairy,  or  creamy  in 
character.  In  some  cases,  owing  to  retention  in  the  uterus,  the  lochia 
is  temporarily  diminished.  At  these  periods  the  temperature  usually 
rises.  Gonococci  can  be  demonstrated  in  the  discharge.  Evidence 
of  gonori'hea  can  generally  be  found  in  the  external  genitalia  and  in 
the  cervix.  The  cervical  canal  is  often  wideh'  dilated,  and  involution 
is  retarded;  the  uterine  walls  are  relaxed,  tender,  and  the  organ  is 
bulkier  than  normal.  In  the  anabasis  of  the  disease  it  is  rarely  pos- 
sible to  palpate  the  appendages  accurately  without  an  anesthetic; 
marked  tenderness  is  likely  to  be  present  in  one  or  both  ovarian  regions. 
Diagnosis. — Gonorrheal  puerperal  infection  must  be  distinguished 
from  the  various  other  conditions  that  produce  pyrexia  during  the 
puerperium,  among  the  most  frequent  of  which  are  mammary  com- 
plications, auto-intoxication  resulting  from  constipation,  especially 
after  a  cathartic  has  been  administered  and  before  the  bowels  have 
moved;  retained  secundines  and  other  forms  of  infection,  such  as  the 
streptococcus,  staphylococcus,  or  colon  bacillus.  Appendicitis,  torsion 
of  the  pedicle  of  tumors,  typhoid  fever,  malaria,  tuberculosis,  and 
the  infectious  fevers  in  general  can  all  usually  be  excluded  without 
great  difficult}'.  Malaria  in  particular  is  often  made  the  scapegoat 
in  puerperal  infection.  It  is  hardly  necessary  to  state  that  a  diag- 
nosis of  malaria  is  not  justifiable  unless  the  Plasmodium  can  be  demon- 
strated in  the  blood  of  the  patient.  Postpuerperal  pyrexia  should 
always  be  considered  of  infectious  origin  until  it  can  be  proved  other- 
wise. Late  onset  of  symptoms,  slow,  regular  pulse,  steady,  moderate 
fever,  and  profuse  purulent  lochia,  are  all  suggestive  of  gonorrheal 
infection.  If  the  anamnesis  is  carefully  inquired  into,  it  will  be  found 
that  most  cases  present  a  history  suggestive  of  a  previous  gonoirheal 
infection.  In  married  women  a  history  of  urethritis  in  the  husband 
is  often  obtainable.  Bacteriologically,  gonococci  can  almost  in- 
variably be  recovered  from  various  portions  of  the  genital  tract.  In 
this  connection,  however,  it  should  be  remembered  that  the  demon- 
stration of  the  gonococcus  does  not  preclude  the  presence  of  other 
microorgani-sms.  In  4  of  Gurd's'  5  cases  the  microorganism  was 
associated  with  the  streptococcus.     Uterine  cultures  made   by  an 

'  Gurcl,  F.  n.:  Montreal  Med.  ,Iour.,  1008,  vol.  xxxvii,  p.  798. 


372  GONORRHEA    IN    WOMEN 

experienced  bacteriologist  who  employs  the  Nicholson  tube   are  of 
great  value  in  doubtful  cases. 

Prognosis. — This  varies  widely  in  different  cases.  The  acuteness 
of  the  infection  is  largely  dependent  upon  the  receptivity  of  the  par- 
ticular patient.  In  some  cases  the  type  of  infection  is  mild,  the 
patient's  resisting  powers  strong,  and  the  acute  symptoms  may  not 
last  for  more  than  a  few  days ;  whereas  in  others  the  attack  continues 
for  a  long  period  and  exacerbations  are  frequent.  If  there  has  been 
marked  loss  of  blood  during  or  following  labor,  the  prognosis  is  less 
favorable.  Subsidence  usually  occurs  gradually.  Webster^  states 
that  embolism  sometimes  occurs.  Death  may  result  from  a  variety 
of  complications,  but  the  gonococcus  alone  rarely  causes  a  fatal  ter- 
mination. A  high  temperature,  and  especially  a  high  pulse-rate,  or 
other  grave  symptoms  usually  indicate  the  presence  of  inicroorganisms 
other  than  the  gonococcus.  Bandler"  states  that  postpartum  in- 
fections are  often  mild.  The  heritage  of  the  majority  of  these  patients 
is  the  semi-invalidism  incident  to  chronic  pelvic  inflammatory  disease 
and  its  accompanying  sterility. 

Prophylactic  Treatment. — This  consists  of  adopting  prophylactic 
measiu-es  before  and  during  labor.  Both  clinical  and  experimental 
work  has  shown  that  the  routine  employment  of  the  prophylactic 
antepartum  vaginal  douche  is  not  only  useless,  but  even  directly  harm- 
ful. This  procedure  has,  therefore,  been  abandoned  by  most  obstet- 
ricians. Whep,  however,  gonorrhea  is  present  in  the  uterus  or  lower 
genital  tract,  practically  all  authorities  agree  that  vaginal  irrigations 
are  indicated  unless  the  infection  is  limited  to  the  vulva  and  urethra. 
In  gonorrheal  cases  at  the  Sloane  Maternity,  Cragin^  directs  the  ad- 
ministration of  a  daily  douche  consisting  of  bichlorid  1 :  5000  during 
the  last  week  of  pregnancy,  and  as  soon  as  labor  commences  a  vaginal 
irrigation  of  0.5  per  cent,  solution  of  lysol.  Williams^  employs  copious 
douches  of  hot  bichlorid  solution  1 :  10,000  twice  daily  during  the 
last  few  weeks  of  pregnancy.  These  douches  are  administered  not  so 
much  in  the  hope  of  curing  the  disease,  as  of  avoiding  infection  of  the 
child's  eyes  during  labor. 

If  gonorrhea  is  present  in  the  external  genitalia,  these  struc- 
tures, and  even  the  vagina  and  cervix,  may  be  painted  with  iodin 
solution  as  soon  as  labor  commences.  This  obviates  the  necessity  of 
washing  the  parts  with   antiseptic   solutions.     The  skin  should  be 

'  Webster,  J.  C:  Diseases  of  Women. 

2  Bandler,  S.  W. :  The  Post-Graduate,  April,  1912,  p.  204. 

'  Cragin:  Amer.  Jour.  Obst.,  1906,  vol.  liii,  p.  770. 

<  Williams,  J.  W.:  Obstetrics,  1903. 


GONORRHEA    IN    PREGNANCY,    LABOR,    AND    THE    PUERPERII'M       373 

absolutely  dry  before  the  application  of  the  iodin,  as  previous  wetting 
of  the  skin  tends  to  cause  swelling  of  the  surface  epithelium  and  pre- 
vents the  penetration  of  the  iodin  to  the  deeper  layers  and  into  the 
crypts  and  glands.  Within  the  vagina  or  in  areas  that  are  norniallj^ 
moist  this  is  not  the  case,  as  the  surface  cells  in  such  localities  are, 
as  it  were,  accustomed  to  moisture,  and  do  not  enlarge,  and,  as  a 
result,  iodin  can  be  effectively  employed.  The  most  suitable  strength 
iodin  to  employ  for  this  purpose  is  a  50  per  cent,  solution  of  the  official 
tincture,  the  dilution  being  made  with  absolute  alcohol.  The  writer 
has,  however,  frequently  applied  the  full-strength  official  tincture, 
and  only  in  a  small  proportion  of  such  cases  was  a  noticeable  irritation 
produced.  If,  however,  more  than  one  application  is  made,  subse- 
quent inconvenience  is  likely  to  be  experienced  by  the  patient  unless 
the  solution  is  diluted. 

If,  before  labor,  the  infection  has  been  confined  to  areas  below 
the  internal  os,  every  effort  should  be  made  during  the  process  of 
delivery  to  avoid  contamination  of  the  uterine  cavity.  For  this 
reason  all  intra-uterine  manipulations  should  be  avoided  when  pos- 
sible. Postpartum  vaginal  douches  of  1:5000  bichlorid  solution,  fol- 
lowed by  sterile  water  or  physiologic  salt  solution,  should  be  ad- 
ministered once  or  twice  daily  with  the  patient  in  the  upright  Fowler 
position.  The  douche  should  be  given  slowly,  and  every  effort  be 
made  to  prevent  the  solution  from  entering  the  uterine  cavity.  The 
douche  nozle  should  have  openings  in  the  sides  only,  as  otherwise  a 
stream  of  fluid  may  be  directed  into  the  cervix.  Some  authorities 
recommend  the  insertion  of  a  temporary  tampon  against  the  cervix 
prior  to  the  administration  of  the  douche,  for  the  purpose  of  walling 
off  the  cervical  canal. 

Lesions  of  the  external  genitalia  should  receive  appropriate  treat- 
ment. If  the  infection  has  previously  been  confined  to  the  external 
genitalia,  the  proper  drainage  of  the  vagina  is,  at  least,  of  theoretic 
advantage,  as  without  intravaginal  manipulations  or  gravity  the 
non-motile  gonococcus  is  unlikely  to  reacli  the  cervix.  Unfortunately, 
in  the  large  majority  of  cases  the  cervix  is  already  contaminated,  and 
infection  to  the  endometrium  can  easily  occur  by  continuity. 

When  the  child's  head  is  born,  or  so(m  afterward,  its  eyes  should 
!)(•  treated  by  the  ("rede  method  of  prophylaxis  for  ophthalmia,  and 
other  methods  adopted  to  prevent  infection  of  the  infant's  eyes,  which 
will  l)e  described  in  detail  in  a  .-<ul)sefiuent  chapter. 

Curative  Treatment  of  Puerperal  Infection  of  Gonorrheal  Origin. — 
In  nio.st  cases  of  postpucrpcrMl  infect  ion  of  tlie  genital  tract  the  author 
believes  that  it   is  the  ilut\    of   ilir   ()b>lctriciaii   to  ascertain   if  tlie 


374  GONORRHEA    IN    AVOMEN 

uterine  cavity  is  empty.  This  may  be  performed  with  the  hand  intro- 
duced into  the  vagina  and  the  fingers  in  the  uterus,  as  recommended 
by  Polak/  or  the  placental  forceps  may  be  employed.  In  any  event, 
no  curetage  should  be  performed.  The  removal  of  retained  secundines 
is  all  that  is  indicated,  and  this  should  be  performed  with  as  little  trauma 
as  possible.  With  a  well-contracted  uterus,  a  closed  cervix,  and  no 
foul  discharge  or  bleeding,  the  uterus  should  not  be  entered,  as  such 
conditions  practically  preclude  the  possibility  of  retained  secundines. 
No  greater  mistake  can  be  made  than  to  employ  routine  curetage  in 
these  cases. 

It  should  be  remembered  that  after  labor  or  abortion  the  gono- 
coccus  usually  produces  localized  lesions,  and  for  this  reason  operative 
intervention  during  the  acute  stage  is  most  unwise,  unless  pus  can 
be  evacuated  without  traversing  the  peritoneal  cavity,  or  in  those 
rare  cases  in  which  general  peritonitis  develops.  It  cannot  be  too 
strongly  urged  that  operative  treatment  in  the  ordinary  case  of 
gonorrheal  puerperal  infection  is  contraindicated  during  the  acute 
stage  of  the  disease.  These  cases,  even  if  untreated,  rarely  proceed 
to  a  fatal  termination,  and  all  that  has  been  said  under  the  heading 
of  The  Selection  of  the  Time  to  Operate  on  Cases  of  Pelvic  Inflam- 
matory Disease  is  true  regarding  these  patients.  The  treatment 
during  the  acute  stage  should  consist  of  a  carefully  regulated,  alcohol- 
free  diet,  which,  if  the  temperature  is  above  100.5°  F.,  should  be 
chiefly  liquid.  .  Cold  sponges  may  be  employed  for  fever.  Regula- 
tion of  the  bowels,  application  to  the  lower  abdomen  of  heat  or 
cold,  and  slow  administration  of  copious  vaginal  irrigations,  with 
the  patient  in  the  upright  Fowler  position,  are  all  indicated.  Pos- 
tural drainage,  secured  by  maintaining  the  patient  in  the  upright 
Fowler  position,  is  of  much  benefit.  If  the  pain  is  severe,  opium 
or  its  derivatives  may  be  required.  Further  medication  is,  as  a 
rule,  unnecessary.  In  protracted  cases,  or  in  those  in  which  there 
is  cardiac  or  general  weakness,  strychnin  is  beneficial.  As  the 
acute  symptoms  tend  to  subside  the  diet  should  be  augmented, 
and  a  tonic  containing  iron,  arsenic,  or  nux  vomica  should  be  pre- 
scribed. It  should  be  borne  in  mind  that  these  patients  are  strictly 
surgical  cases,  and  that  operative  intervention  may  be  required  at 
any  time.  For  this  reason  patients  are  best  treated  in  a  hospital, 
where  they  can  be  under  constant  and  careful  supervision.  The 
frequency  of  the  pelvic  examinations  will  necessarily  vary  with  the 
individual  cases,  but  should,  however,  be  made  only  sufficiently  often 

'  Polak,  .1.  O.:  Surg.,  Gyn.,  and  Obst.,  Julv,  1911:  also  Jour.  Amer.  Med.  Assoc, 
August  31,  1912,  p.  707. 


GONORRHEA    IN    PREGNANCY,    LABOR,    AND    THE    PUERPERIUM       375 

to  keep  the  surgeon  acquainted  with  the  intrapelvic  changes  that  are 
taking  place.  To  safeguard  others,  the  nurse  and  sometimes  the 
patient  should  be  warned  of  the  infectious  nature  of  the  leukorrhea. 
Under  no  conditions  should  the  child  be  allowed  to  sleep  in  the  same 
bed  with  the  mother,  as  under  such  circumstances  the  danger  of  it 
contracting  an  ophthalmia,  or,  if  it  is  a  girl,  a  vaginitis,  is  very  great. 
The  Indications  for  Operation  During  the  Acute  Stage. — These 
may  be  brieflj'  summarized.  When  it  is  possible  to  evacuate  pus 
without  traversing  the  peritoneal  cavity,  as  in  cases  in  which  an 
abscess  tends  to  point  in  the  neighborhood  of  the  inguinal  canal  or 
in  the  vagina,  operation  may  be  undertaken.  Such  collections  should 
be  inci-sed,  evacuated,  and  packed  with  sterile  gauze.  Immediate 
operation  is  also  generally  indicated  if  a  diffuse  peritonitis  develops. 
Finally  operation  may  be  required  in  extremely  protracted  cases  that 
show  no  tendency  to  improve  under  the  palliative  treatment.  Such 
cases  are  seldom  encountered. 


CHAPTER  XVI 
GONORRHEA  IN  THE  EXTREMES  OF  LIFE 

GONORRHEA  IN  CHILDREN 

The  gonococcus  is  the  most  frequent  etiologic  factor  in  the  pro- 
duction of  inflammatory  diseases  of  a  gynecologic  nature  occurring 
in  children. 

Vulvovaginitis. — In  the  Johns  Hopkins  Hospital  Dispensary  Hurdon* 
found  the  gonococcus  in  63  per  cent,  of  all  cases  of  vulvitis  in  children. 
Among  24  cases  of  vulvovaginitis  Koplik-  was  able  to  demonstrate 
the  gonococcus  in  17.  Romniceanu  and  Robin'  report  150  cases  of 
vaginitis,  of  which  130  were  of  gonorrheal  origin.  Dukelski*  found 
the  gonococcus  in  80  per  cent,  of  his  cases.  Plomley^  was  able  to 
demonstrate  the  organism  in  85.7  per  cent,  of  a  series  of  42  female 
children  who  had  a  leukorrhea.  Welt-Kakels^  states  that  the  majority 
of  the  190  cases  observed  by  her  at  the  Mount  Sinai  Hospital  Dis- 
pensary were  due  to  this  cause.  A  similar  statement  is  made  by 
Pollack.^  Gonorrhea  is  comparatively  infrequent  among  female 
children  of  the  better  class,  but  among  the  poor  and  those  comprising 
the  general  run  of  ward  patients  this  variety  of  infection  is  extremely 
prevalent.  Indeed,  Holt*  states  that  it  occurs  in  from  2  to  10  per 
cent,  of  all  inmates  of  institutions,  such  as  day  nurseries,  homes  for 
foundlings,  asylums,  and  children's  wards  of  general  hospitals.  Kim- 
balP  found,  among  600  children  admitted  to  the  public  ward  of  the 
Babies'  Hospital,  New  York,  70  cases  of  gonorrheal  vulvovaginitis. 
Hamilton  states  that  4  per  cent,  of  all  the  applicants  to  the  same 
institution  were  found  to  have  gonorrheal  vulvovaginitis.  Pott'" 
observed  86  cases  among  3921  girls. 

Epidemics  are  frequent.     Four  epidemics  were  observed  by  Holt^^ 

'  Hurdon,  E.:  Kelly  and  Noble:  Gyn.  and  Abdom.  Surg.,  1907,  vol.  i,  p.  811,  first  ed. 

^  Koplik:  Jour.  Cutan.  and  Gen.-urin.  Dis.,  1893,  vol.  ii. 

'  Romniceanu  and  Robin:  Wien.  med.  Presse,  1901,  vol.  xlii,  Xo.  43,  p.  1970. 

*  Dukelski:  Jahrb.  f.  Kinderheilk.,  1904,  vol.  lix,  p.  397. 

*  Plomley:  Australasian  Med.  Gaz.,  September  20,  1906,  p.  4.55. 

6  Welt-Kakels,  S.:  New  York  Med.  Jour.,  1904,  vol.  Ixxx,  p.  689. 
'Pollack:  Amer.  Jour.  Dermat.  and  Gen.-urin.  Dis.,  July,  1909,  p.  289. 
»  Holt:   Diseases  of  Infancy  and  Childhood,  1908,  p.  689,  fourth  ed. 
'  Kimball:  Med.  Rec,  1903,  vol.  Ixiv,  p.  761,  No.  20. 
'"  Pott:  Jahrb.  f.  Kinderheilk.,  1883,  vol.  xix. 

"  Holt:  New  York  Med.  Jour,  and  Phila.  Med.  Jour.,  March  IS,  1905. 

:S76 


GONORRHEA    IN    THE    EXTREMES    OF    LIFE  377 

in  the  Babies'  Hospital  between  1899  and  1904.  Skutsch'  described 
an  epidemic  in  which  236  school-girls  were  sufferers.  The  infection 
was  contracted  in  a  crowded  public  bath-house.  The  patients  varied 
from  six  to  fourteen  \'ears  of  age.  All  manifested  evidences  of  in- 
fection in  periods  varying  from  one  to  two  weeks.  A  number  of  boys 
used  the  same  bath-house,  but  none  were  diseased.  Cotton,^  Kim- 
ball,' Baer,^  and  many  others  report  epidemics  of  greater  or  less 
severity. 

Modes  of  Infection. — Gonorrhea  maj'  be  propagated  by  accidental 
infection,  by  the  infectionist,  by  the  sadist,  bj^  precocious  sexual 
intercourse,  and  in  rare  instances  by  the  passage  of  the  child  through 
an  infected  maternal  birth-canal.  Vulvovaginitis  neonatorum  is  ex- 
tremel}'  infrequent,  although  ^\icheP  states  that  this  method  of  infec- 
tion is  probably  more  common  than  is  generally  supposed.  Cases  of 
gonorrheal  vulvovaginitis  neonatorum  have  been  reported  by  Epstein" 
(3  cases,  2  of  which  were  associated  with  gonorrheal  ophthalmia), 
Aichel,"  Woods, ^  Strzeminski,  Koblanck,^  and  Dowd.'"  Breech  presen- 
tations would  seem  to  favor  this  method  of  infection.  This  was  the 
case  in  Woods'  patient.  Gonorrheal  vulvovaginitis  neonatorum  would 
doubtless  be  more  frequent  if  it  were  not  for  the  fact  that  at  the 
first  bath  given  the  infant  the  genitalia  are  usually  cleansed,  and 
that,  in  cephalic  presentation,  the  parts  are  more  or  less  protected 
during  the  passage  of  the  child  through  the  birth-canal.  There  is 
reason  to  believe  that  intragenital  infection  may  occur  in  rare 
instances. 

The  manner  of  infection  naturally  \aries  with  the  age  of  the  child. 
In  children  less  than  eight  or  ten  years  of  age  the  large  majority  of 
cases  are  the  result  of  accidental  contamination,  usually  by  means  of 
infected  thermometers,  underclothing,  bed-linen,  napkins,  towels, 
sponges,  wash-cloths,  syringes,  bath-tubs,  or  even  by  bath-water, 
the  first  two  especially  being  frequent  sources  of  infection  in  hospital 
wards.     Excluding  those  cases  of  gonorrhea  that  are  contracted  during 

'  Skiil.sc'h;   Iiuiug.  Di.-.s.,  Jciui,  IS'.M. 

'  Cotton:  Arch.  f.  Pcdiat.,  New  York,  190.5,  vol.  x.\ii,  p.  100. 
'  Kimball:   Med.  Rco.,  1903,  vol.  Ixiv,  p.  761,  No.  20. 
'  Hiior:  Jour.  Infer.  Dis,,  1904,  vol.  i,  p.  313. 
»  Aichel,  O.:   Ilatier's  Heitriine,  1900,  vol.  ii,  No.  2. 

MOp.stein:  .\rch.  f.  Dermal,  u.  Svph.,  1S91,  vol.  .\xiii,  p.  3;  also  Tiaile  iles  .Maladies 
de  I'enfanl,  1S93,  vol.  iii. 

"  Aichel,  ().:   IlaKcr'.s  Beitriine,  1900,  vol.  ii,  No.  2. 
•  Woorl.s,  R.  v.:  Anier.  Jour.  Med.  Sci.,  1903,  p.  311. 
'  KoMaiick:  Cent.  f.  Gyn.,  July  13,  1S9.5,  p.  7.")S. 
'"  Dowd:   .\iiti.  of  Sure.,  February,  1902. 


378  GONORRHEA    IN    WOMEN 

the  child's  stay  in  an  institution,  Pott'  has  shown  that  90  per  cent,  of 
the  mothers  of  these  patients  had  a  more  or  less  pronounced  leukorrhea, 
and  infection  from  such  sources  doubtless  constitutes  a  large  propor- 
tion of  the  original  contaminations.  Morgenstern  and  others  have 
reported  such  cases.  Children  may  also  contract  gonorrhea  from  in- 
fected toilet-seats,  from  sitting  about  on  doorsteps  or  on  rugs  that 
have  previously  been  soiled  by  a  filthy  and  perhaps  drunken  parent. 
At  least  one  case  is  on  record  in  which  a  girl  received  an  infection  at 
her  first  menstruation  from  using  a  vulvar  pad  previously  infected 
by  an  older  sister.  Atmospheric  infection  does  not  occur.  In  older 
children  other  modes  of  infection  are  relatively  more  frequent.  Pol- 
lack- has  studied  187  cases  of  acquired  venereal  infection  occurring 
among  children  treated  in  the  Johns  Hopkins  Hospital  Dispensary, 
and  finds  that  the  greatest  number  (24)  were  infected  at  six  years. 
Between  six  and  twelve  years  of  age  the  number  dropped  to  about  9, 
but  after  this  gradually  rose,  and  at  the  fifteenth  year  the  number  of 
infected  cases  was  found  to  be  20.  Of  Pott's'  86  cases,  5G  were  under 
five  years  of  age. 

One  of  the  most  frequent  causes  of  outrages  committed  on  chil- 
dren is  the  superstition  that  if  a  person  affected  with  an  acute 
gonorrhea  can  transmit  the  disease  to  a  virgin,  he  or  she,  as  the 
case  may  be,  will  be  immediately  cured.  Incredible  as  this  may 
seem,  the  belief  is  wide-spread,  especially  among  ignorant  foreigners, 
and  particularly  those  coming  from  southern  Europe.  As  early  as 
1853  Wilde,''  of  Dublin,  reports  the  histories  of  cases  infected  as  a 
result  of  this  superstition.  That  this  method  of  infection  is  not  in- 
frequent is  shown  by  the  fact  that  Seippel'  has,  during  the  last  six 
months,  examined  53  girls,  most  of  whom  were  attacked  as  a  result 
of  this  superstition.  Of  these,  13  were  under  eleven  years  of  age. 
Krafft-Ebing'^  also  refers  to  numerous  such  cases.  The  infectionist  is 
usually  a  man,  although  Wolbarst'  records  a  case  in  which  a  number 
of  little  boys  were  thus  contaminated  by  a  prostitute.  According 
to  Pollack,*  many  of  the  children  infected  as  a  result  of  this  super- 
stition present  no  evidence  of  rape,  the  infectionist  apparently  not 
desiring  coitus. 

■  Pott:  Jahrb.  f.  Kinderheilk.,  188.3,  vol.  xix. 

-  Pollack:  Amer.  Jour.  Dermat.  and  Gen.-urin.  Dis.,  July,  1909,  p.  289. 

'  Pott:  Jahrb.  f.  Kinderheilkunde,  1883,  vol.  xix. 

*  Wilde:  Med.  Times  and  Gazette,  Dublin,  September  10,  18.53. 

*  Seippel,  C.  P.:  lUus.  Med.  Jour.,  July,  1912,  p.  50. 

«  Krafft-Ebing:  P.sychopathia  Sexualis,  English  ed.,  1906,  p.  561. 

'  Wolbarst :  Jour.  .\mer.  Med.  .\ssoc.,  September  28,  1901,  p.  829. 

"  Poilaik:  Amer.  Jour.  Dermat.  and  Gen.-urin.  Dis.,  July,  1909,  p.  289. 


GONORRHEA  IN  THE  EXTREMES  OF  LIFE  379 

In  examining  children  it  should  be  remembered  that  the  young 
child's  hymen  does  not  form  carunculse  myrtiformes  when  rup- 
tured, but  simply  shows  serrations  on  its  free  border,  and  on 
account  of  the  delicacy  of  the  membrane,  often  bleeds  but  little. 
In  young  girls  in  whom  coitus  frequently  occurs  the  hymen  entirely 
disappears.  Pollack'  believes  that  between  800  to  1000  children  are 
infected  annually  in  Baltimore.  The  sadist  and  individuals  affected 
with  other  forms  of  sexual  perversion  are  also  accountable  for  a  definite 
proportion  of  assaults  upon  little  girls.  Precocious  sexual  intercourse 
among  children  is  probably  comparatively  infrequent,  and,  as  a  re- 
sult, gonorrhea  is  rarely  contracted  in  this  way.  As  the  girls  grow 
older  and  reach  the  age  of  thirteen  or  fourteen,  or  perhaps  even  a 
year  or  two  earlier,  the  proportion  that  acquire  gonorrhea  during 
coitus  becomes  much  greater.  After  the  establishment  of  menstruation 
gonorrhea  in  girls  differs  in  no  essential  from  the  same  disease  as  it 
occurs  in  adults. 

Symptoms. — Among  young  girls  and  infants  the  most  frequent  parts 
of  the  genital  tract  attacked  by  the  gonococcus  are  the  vagina  and  vulva. 
The  infection  seldom  extends  to  the  body  of  the  uterus  or  adnexa 
in  young  children  in  whom  menstruation  has  not  yet  been  established, 
although  involvement  of  the  portio  vaginalis  probably  occurs  in  the 
majority  of  cases.  Indeed,  Perrin-  states  that  in  a  series  of  about 
100  cases  reported  by  him  the  vaginal  cervix  was  involved  in  every 
instance.  Even  in  latent  cases,  when  the  vulvovaginitis  seemed 
about  cured,  gonococci  were  often  found  at  the  external  os.  Jung' 
states  that  the  gonococci  seldom  penetrate  above  the  external  os. 

The  iiifrcfiuency  of  vaginitis  among  adults  and  its  great  prevalence 
among  infants  and  little  girls  are  most  striking,  and  can  be  explained 
by  the  fact  that  in  the  latter  the  lining  of  the  vagina  is  thin,  tender, 
and  undeveloped,  and  is,  therefore,  receptive  to  the  gonococcus. 
Cases  differ  markedh'  in  severity:  some  are  subacute  from  the  onset, 
whereas  in  others  the  acute  stage  is  productive  of  serious  symptoms. 
In  the  mild  cases  only  a  slight  itching  or  burning  is  present  in  the 
affected  areas.  Ardor  urinai  is  generally  a  pronounced  symptom, 
and  may  occur  even  when  the  urethra  is  not  involved.  Retention 
of  urine  due  to  pain  is  not  infrequent.  Slightly  painful  micturition 
often  persists,  even  after  the  subsidence  of  the  acute  symptoms. 
Ill  severe  acute  cases — and  this  applies  to  all  vulvovaginal  infections 
in  l)oth  adults  and  children  the  pain  is  greatly  increased  by  walking. 
In  order  to  obtain  relief  the  patient  must  go  to  bed  and  lie  with  the 

'  I'ollack:  Loc.  cil.         "■  IVrrin:  l{cv.  Mrii.  dc  liiSi)iiin,se  Roinamle,  Xovcnihor'ii),  l'.)ll. 
'  .lunsj;  Zcnt.  f.  Clyn.,  lOO-l,  vol.  xxviii. 


380  GONORRHEA    IN    WOMEN 

thighs  widely  separated.  On  examination  a  discharge,  which  may 
vary  from  a  shght  moisture  to  a  copious,  thick,  purulent  leukorrhea, 
will  be  observed.  This  discharge  is  yellow  or  yellowish-green,  and 
in  severe  cases  may  be  blood  tinged  or  of  a  dirty,  reddish-brown  color. 
The  discharge  contains  gonococci,  which  during  the  acute  stage 
can  be  easily  detected.  In  long-standing  chronic  cases  the  demon- 
stration of  these  microorganisms  is  often  difficult.  In  infants  the 
amount  of  discharge  is  frequently  small.  In  neglected  cases  ex- 
coriations are  usually  present  about  the  external  genitaha,  on  the 
perineum,  the  inner  and  upper  part  of  the  thighs,  and  occasionally 
in  the  genitocrural  region.  Crusts  may  form,  which,  on  removal, 
leave  a  bleeding  area  behind.  Annoying  exanthemata  and  a  foul 
odor  may  result.  Condylomata  may  occur.  Small  erosions  frequently 
surround  the  orifice  of  the  vagina  and  the  urethra,  if  the  latter  is  in- 
volved. The  labia,  and  especially  the  labia  majora,  are  swollen, 
tender,  and  are  frequently  found  partially  glued  together.  The  hymen 
and  the  lining  membrane  of  the  vagina  are  reddened  and  edematous, 
and  may  bleed  when  touched.  Examination  during  the  acute  stage 
causes  pain,  but  when  the  disease  has  become  chronic,  this  is  by  no 
means  always  the  case.  Urethritis  is  the  most  frequent  complication, 
but  is  found  only  in  the  minority  of  cases.  In  Pollack's'  series  of 
187  cases  urethritis  was  present  in  18  per  cent,  of  the  patients,  while 
Scheuer^  reports  this  complication  as  occurring  15  times  in  a  series 
of  39  cases. 

In  some  cases  a  caruncle  develops  and  leads  to  painful  symjitoms. 
When  the  urethra  is  involved,  the  usual  symptoms  of  an  inflammation 
of  this  area  are  present.  During  the  acute  stage  slight  fever,  the  tem- 
perature sometimes  reaching  100°  to  101°  F.,  with  its  accompanying 
symptoms,  may  be  present,  but  when  the  case  becomes  chronic  or 
during  mild  attacks,  these  symptoms  are  absent. 

Acute  inflammatory  symptoms  usually  disappear  in  from  three 
to  six  weeks,  after  which  time  the  discharge  becomes  scanty,  milky  or 
serous  in  character,  and  the  pain  disappears  or  is  greatly  alleviated. 
At  this  stage  the  symptoms  are  often  extremely  mild  and  are  fre- 
quently overlooked.  Severe  constitutional  symptoms  are  usually  in- 
dicative of  the  onset  of  complications.  Peritonitis  and  cardiac,  renal, 
or  other  complications  may  occur.  Ophthalmia  is  not  uncommon. 
Septicemia  or  other  manifestations  of  a  general  infection,  such  as 
arthritis  or  endocarditis,  may  result.     KimbalP  states  that  among  70 

'  Pollack:  Amer.  Jour.  Dermat.,  etc.,  July,  1909. 

=  Seheuer:  Wien.  klin.  Woch.,  1909,  No.  18. 

■■•  Kimball:   Med.  Rec,  November  14,  1903,  p.  701. 


GONORRHEA    IN    THE    EXTREMES    OF    LIFE  381 

cases  of  vulvovaginitis  occurring  in  the  Babies'  Hospital,  10  cases 
of  arthritis  developed.  Unless  gonorrheal  vaginitis  receives  proper 
treatment,  adhesions  or  atresia  may  occur.  Indeed,  Findley^  states 
that  certain  so-called  congenital  anomalies,  such  as  imperforate 
hymen,  adhesions,  and  malformation  of  the  uterus  and  adnexa,  may 
be  ascribed  to  gonorrhea  acquired  in  utcro.  Hamilton-  states  that 
among  344  cases  of  gonorrheal  vulvovaginitis  occurring  in  children, 
the  average  age  of  whom  was  five  years,  3  cases  of  arthritis  developed. 

Diagnosis. — This  is  based  on  the  presence  of  the  symptoms  just 
described  and  the  finding  of  gonococci  in  the  vaginal  discharge.  In 
this  connection  it  should  be  remembered  that  in  those  cases  in  which 
the  discharge  is  scant  or  in  which  the  di.sease  is  chronic,  the  demon- 
stration of  the  specific  microorganism  is  often  difficult.  For  this 
reason  all  vaginal  discharges  occurring  in  children  should  be  viewed 
with  suspicion,  and  the  cases  treated,  so  far  as  prophylactic  methods 
and  isolation  are  concerned,  as  if  they  were  of  gonorrheal  origin, 
until  at  least  three  bacteriologic  examinations,  performed  under 
circumstances  favorable  for  the  detection  of  the  gonococcus,  have 
proved  negative.  It  is  only  by  adopting  the  strictest  prophylactic 
measures  that  the  spread  of  the  disease  can  be  checked.  This  is 
especially  the  case  in  institutions.  Chappie'  and  others  have  re- 
ported cases  of  pneumococcal  and  other  forms  of  vulvovaginitis,  in 
children  which  were  clinically  indistinguishable  from  gonorrheal 
lesions. 

Prophylactic  Treatment. — Prophylaxis  consists  of  making  frp(iuent 
bacteriologic  examinations  of  all  vaginal  discharges  occurring  in  little 
girls  and  in  the  strictest  isolation  of  infected  cases.  In  institutions 
this  can  hardly  be  too  rigidly  carried  out.  The  importance  of  making 
an  early  diagnosis  and  insuring  complete  isolation  cannot  be  too 
strongly  emphasized.  The  nurses  attending  the  children  should 
also  be  isolated,  and  all  contaminated  dressings  should  be  l)urned. 
Special  thermometers,  douche-pans,  and  other  instruments  used  in 
the  treatment  of  these  cases  must  be  employed.  It  is  only  by  main- 
taining strictest  quarantine  that  the  spread  of  the  disease  to  other 
children  can  be  prevented.  Indeed,  the  numerous  epidemics  that 
occurred  in  different  well-conducted  institutions  years  ago  have  led 
to  the  assertion  that  this  variety  of  gonorrhea  was  spread  by  air 
infe(;tion.  This  is  now  known  to  l)e  incorrect,  but  the  ease  and 
rapidity   with   which  gonorrheal    vulvovaginitis   may   l)e   propagated 

'  I'iiwllcy,  I'.:   Wcstorn  .Mc.i.  Rev.,  .Vi)ril,  I'.MJ,  v.. I.  wii,  .\<>.  1,  |).  ISd. 
-'  Ilairiilton:  .lour,  .\incr.  Mcfl.  .\.s.soe.,  .\piil  '.I,  I'.IHI. 
M'hiipple,  H.:   Lancet,  .lune  22,  1912. 


382  GONORRHEA   IN   WOMEN 

through  a  ward  are  most  surprising.  A  further  difficulty  in  checking 
the  spread  of  gonorrheal  vulvovaginitis  lies  in  the  fact  that  not  a  few 
of  the  subacute  and  chronic  cases  present  practically  no  subjective 
symptoms.  For  this  reason  some  institutions  make  a  practice  of 
routinely  examining  a  smear  from  the  vaginal  secretion  of  each  child 
upon  admittance,  and  of  isolating  the  case  until  the  bacteriologic 
report  has  been  made. 

The  importance  of  making  a  routine  examination  in  institutions 
is  shown  by  the  statistics  of  Seippel,^  who  states  that  of  252  cases  of 
gonorrheal  vulvovaginitis  admitted  to  a  hospital,  136,  or  54  per  cent., 
were  brought  for  some  condition  other  than  the  vulvitis. 

Prophylactic  measures  for  nurses  and  physicians  brought  in  con- 
tact with  these  cases  should  be  thoroughly  carried  out.  Numerous 
cases  are  on  record  in  which  ophthalmia  has  been  contracted  as  a 
result  of  carelessness  in  this  respect.  All  adults  suffering  from  gon- 
orrhea should  be  notified  of  the  infectious  nature  of  the  disease; 
women  suffering  from  genital  gonorrhea  should  not  allow  their  young 
children  to  sleep  in  the  same  bed  with  them.  Trenwith^  states  that 
in  the  large  majority  of  his  cases  vulvovaginitis  could  be  indirectly 
traced  to  gonorrhea  in  the  father. 

Recognizing  the  frequency  of  gonorrhea  in  childhood,  and  realiz- 
ing the  impossibility  of  treating  these  cases  successfully  without 
special  organization  for  the  purpose,  the  Mount  Sinai  Hospital  Dis- 
pensary (New  York)  has  inaugurated  a  special  class  for  the  treatment 
of  these  cases,  and  has  appointed  a  special  physician  to  look  after  the 
department,  who  is  assisted  by  a  graduate  nurse.  The  cases  enrolled 
since  the  organization  of  this  class  are  so  numerous  that  the  dispensary 
has  been  compelled  to  restrict  its  treatment  to  children  residing  in 
the  immediate  neighborhood.  The  New  York  Medical  JournaP 
suggests  the  organization  of  similar  classes  in  other  parts  of  the  city. 

Curative  Treatment. — This  should  be  based  on  the  same  general 
principles  as  previously  indicated  as  suitable  for  the  same  condition 
in  the  adult,  with  the  exception  that  in  the  child  antiseptic  washes 
and  irrigating  fluids  must  necessarily  be  somewhat  weaker  in 
strength  on  account  of  the  delicacy  of  the  lining  membrane  of  the 
vagina  in  the  young.  Wagner^  recommends  copious  douches — 20 
to  25  liters — of  sterile  water  at  45°  C.  once  daily  for  the  treatment  of 
this  condition.     He  has  been  employing  this  treatment  for  the  last 

'  Seippcl,  C.  P.:  111.  Med.  Jour.,  July,  1912,  p.  50. 

*  Trenwith:  New  York  Med.  Jour.,  February  3,  1906,  p.  240. 

*  August  17,  1912,  p.  339. 

*  Wagner:  Berlin,  klin.  Woch.,  December  25,  1911,  No.  52. 


GONORRHEA    IN    THE    EXTREMES    OF    LIFE  383 

year  in  his  service  at  Frankfort  a.  M.,  with  excellent  results.  Menge' 
employs  camomile  tea  to  cleanse  the  external  genitalia,  and  1  or 
2  per  cent,  silver  nitrate  for  the  vagina.  Doleris-  advises  irrigations 
of  potassium  permanganate  and  the  application  of  an  ointment  com- 
posed of  benzoin,  camphor,  and  cubebs,  5  grains  of  each  to  25  grains 
of  petrolatum,  by  means  of  tampons.  If  the  hymen  is  intact  and  the 
disease  is  persistent,  or  if  the  membrane  is  of  such  character  as  seri- 
ously to  interfere  with  the  necessary  treatments,  it  will  in  many  cases 
be  wise  to  sacrifice  this  structure,  so  that  more  thorough  treatment 
may  be  instituted.  Absolute  cleanUness  is  essential.  Even  in  the 
most  carefully  treated  cases  the  disease  is  eradicated  only  with  ex- 
treme difficulty  and  relapses  are  of  frequent  occurrence. 

In  some  cases  it  is  possible  to  treat  the  vagina  and  cervix  through 
a  cystoscope.  The  instrument  can  usually  be  introduced  through 
the  hymen  without  injuring  this  structure.  Perrin^  employs  an  endo- 
scope, and  applies  a  solution  of  protargol.  glycerin,  and  distilled  water, 
and  follows  this  by  the  introduction  of  a  small  tampon  of  absorbent 
cotton,  moistened  in  a  similar  solution,  between  the  labia.  In  100 
cases  treated  bj'  this  method  Perrin  states  that  cures  were  obtained 
in  periods  varying  from  two  weeks  to  twenty  days.  KimbalP  states 
that  gonorrheal  vulvovaginitis  "is  more  amenable  to  treatment  in 
children  under  one  year  of  age  than  in  older  ones.  In  Cotton's^ 
cases  the  average  duration  of  the  disease  was  between  three  and  four 
months,  whereas  Skutsch"'  states  that  after  twelve  weeks  of  treatment 
the  vaginal  discharge  from  140  cases  was  examined,  and  gonococci 
were  demonstrated  in  43  per  cent,  of  the  patients.  Epstein"  asserts 
that  he  has  often  seen  cases  lasting  from  infancy  until  the  child  has 
attained  an  age  of  nine  or  ten  years,  and  Bruschke*  reports  cases  per- 
sisting for  four  years  in  spite  of  active  treatment.  Hamilton"  records 
that  of  61  cases  of  gonorrheal  vaginitis  discharged  as  cured,  14  returned 
with  recurrences  of  the  condition  in  periods  varying  from  six  months 
to  two  years.  His  requisite  for  cure  was  four  consecutive  negative 
bactcriologic  examinations  (smears)  conducted  at  weeklj''  intervals. 
If  the  case  can  be  properly  treated,  a  duration  of  four  or  five  months 

'  Mengo,  K.:   Iliiinlb.  d.  GfSchlL'chtskrankhc'il(.'n,  \'ionna,  I'.UU. 

2  Doleris,  P.:  Pari.s  M<''<1.,  May  4,  1912. 

'  Perrin:   Rev.  \l6i\.  dc  la  Souisse  Romandc,  Xoveinl)er  20,  1911. 

*  Kiinljall:   Mod.  Hoc,  vol.  Ixiv,  No.  20. 
'Cotton:  .Aroh.  f.  Podiat.,  190."),  vol.  xxii,  |).  100. 
'Skut.sch:   Inaugural  Di.ss.,  .lona,  1891. 

'  Epstein:  Traitc"'  dos  nialadie.s  de  rcnfanco,  1893,  vol.  iii. 

*  Bruschke:   Tlierapie  dor  (iouonwart,  1902. 

'■■  Hamilton:  .lour,  .\iiior.  Moil,  .\ssoo.,  jVpril  9,  1910. 


384  GONORRHEA    IN    WOMEN 

must  be  viewed  as  exceptional.  A  cure  should  be  expected  in  a  much 
shorter  time,  provided  the  treatment  is  properly  applied.  The  long 
duration  in  many  cases  is  due  to  the  difficulty  in  persuading  the 
parents  to  bring  their  children  for  routine  treatment  after  the  dis- 
charge lessens. 

Trenwith^  found  that  the  average  duration  of  the  disease,  in  a 
series  of  12  cases  that  he  was  able  to  follow  carefully,  was  four  and 
one-quarter  months. 

It  is  interesting,  however,  to  note  here  that  Sanger-  and  Marx^  call 
attention  to  the  fact  that  some  cases  of  pelvic  inflammatory  disease 
in  young  virgins  may  be  produced  by  the  persistence  of  a  gonorrheal 
vulvovaginitis  contracted  during  infancy.  Currier^  believes  that 
many  undeveloped  uteri  which  cause  dysmenorrhea  and  sterility 
are  the  result  of  gonorrheal  vulvovaginitis  of  childhood.  Especial 
care  must  be  taken  entirely  to  eradicate  the  infection.  A  case  should 
be  pronounced  cured  only  after  at  least  three  negative  bacteriologic 
examinations  and  disappearance  of  all  local  symptoms. 

Dispensary  cases,  because  of  the  difficulty  of  obtaining  routine 
and  thorough  treatment,  are  productive  of  particularly  unsatisfactory 
results.     Complications  require  special  treatment. 

Complications. — These  are  frequent,  especially  in  neglected  or  un- 
treated cases. 

Inguinal  adenitis  often  occurs,  but  rarely  progresses  to  the  sup- 
purative stage.  In  Pollack's  series  of  187  cases  buboes  were  present  in 
28,  or  15  per  cent.     Only  2  advanced  to  the  stage  of  pus-formation. 

Cystitis. — If  the  urethra  is  involved,  cystitis  may  develop,  but 
bladder  complications  are,  as  a  rule,  seldom  encountered.  Thus 
Bruschke'^  reports  1  case  of  cystitis  occurring  among  50  cases  of  vag- 
initis. 

Bartholinitis  is  not  infrequent,  and  differs  in  no  essential  from  a 
similar  condition  in  the  adult. 

Condylomata  Acuminata. — Venereal  warts  are  frequently  seen  in 
neglected  cases,  and  in  some  instances  attain  considerable  size. 

Arthritis  is  moderately  frequent,  even  in  young  infants.  It  is 
generallj^   accompanied    by    synrptoms    of   systemic    infection,    and 

'  Trenwith,  W.  D.:  New  York  Med.  Jour.,  February  .3,  1906,  p.  240. 

-  Sanger:  Quoted  by  Welt-Kakels,  S.:  New  York  Med.  .Jour,  and  Phila.  Med.  Jour., 
October  8,  1904. 

^  Marx:  Gaz.  d.  Gyn.,  November  15,  1895. 

■•  Currier:  Quoted  by  Welt-Kakels,  8.;  New  York  Med.  Jour,  and  Phila.  Mod.  Jour., 
October  8,  1904. 

'  Bruschke:  Quoted  by  Welt-Kakels,  S.:  New  York  Med.  Jour,  and  Phila.  Med. 
Jour.,  October  22,  1904. 


GONORRHEA    IX    THE    EXTREMES    OF   LIFE  385 

most  frequently  affects  the  wrist,  elbow,  ankle,  knee,  fingers,  toes, 
or  other  small  joints.  It  is  usualh"  multiple  at  the  onset  and  later 
locahzes  to  one  or  occasionally  more  joints.  It  may  be  acute,  sub- 
acute, or  rarely  suppurative  in  character.  In  infants  the  subacute 
variety  is  most  prevalent.  Koplik'  reports  2  cases  occurring  in  a 
series  of  100  cases  of  vulvovaginitis.  In  Welt-Kakels'-  series  of  190 
cases  arthritis  developed  in  3  patients,  whereas  in  Pollack's  group 
there  were  3  cases.  In  1897  Epstein^  collected  28  of  these  cases  from 
the  literature  and  added  2  of  his  own.  He  remarks  upon  the  fre- 
quency of  this  condition,  and  believes  that  the  gonorrheal  origin  is 
often  overlooked. 

Tenonitis. — Seiffert^  has  reported  a  case  of  tenonitis  in  a  child 
suffering  from  gonorrheal  vulvovaginitis.  Gonococci  were  demon- 
strated in  the  fluid  removed  by  puncture. 

Ophthalmia,  often  the  result  of  hand  infection,  is  not  uncommon, 
particularly  in  neglected  cases. 

Proctitis  may  occur,  and  differs  in  no  respect  from  a  similar  con- 
dition in  the  adult.     It  is  present  in  from  1  to  5  per  cent,  of  all  cases. 

Kaumheimer^  believes  proctitis  to  be  more  freciuent  than  is  generally 
supposed;  he  emphasizes  the  fact  that  in  cases  of  vulvovaginitis  the 
temperature  should  not  be  taken  per  rectum,  owing  to  the  dangers 
of  infection.  He  states  that  in  many  eases  of  proctitis  the  symptoms 
are  extremely  mild. 

Peritonitis  is  not  an  infreciueiit  (■omi)lication  of  gonorrheal  vulvo- 
vaginitis, although  Holt"  states  that  in  one  series  of  273  cases  of  gonor- 
rheal vulvovaginitis  no  extension  to  the  tubes,  peritoneum,  or  bladder 
was  observed.  As  compared  with  similar  conditions  in  the  adult, 
gonorrhea  of  the  uterus  and  adnexa  is  extremely  infrequent.  This  may 
be  accounted  for  by  the  fact  that  prior  to  the  establishment  of  men- 
struation the  cervical  canal  is  tightly  contracted  and  more  or  less 
occluded  by  a  plug  of  thick,  tenacious  cervical  nmcus.  The  compara- 
tive rarity  of  extension  upward  of  gonorrheal  vulvovaginitis  in  children 
is  a  further  proof,  if  such  were  needed,  of  the  statement  previously  made 
that  the  spread  of  this  disease  to  the  endometrium  of  the  uterus  in  the 
adult  almost  invariably  occurs  either  at  a  menstrual  period,  immediately 
follows  the  emptying  of  a  pregnant  uterus,  or  as  a  result  of  intra-uterine 
manipulations.     In  the  child,  these  conditions  being  absent,  exten.sion 

'  Koplik:  Joiir.  Cutan.  and  Gpn.-iirin.  Dis.,  1892,  vol.  x. 

Wclt-Kakcls,  .S.:  New  York  Mod.  .(our.  and  Phila.  .Mod.  .Jour.,  Octoh.r  I.'.',  lilOl. 

lOp.stciii:  Trait('>  dc.;  maladies  <lf  rcufimcc,  ISOT,  vol.  iii. 
'  .ScifTiTt :   .lahr.  f.  Kimlcrlicilkundc,  IS'.Mi. 

Kaurnhciiiwr:    Miinch.  i.icd.  Wo.h.,  May  .i,  I'.IIO. 

Holt:   New  York  .Mod.  .lour,  and  I'hila.  .Med.  .Jour.,  .Marr-li  IS,  IIH).'). 


386  GONORRHEA    IN    WOMEN 

upward  rarely  takes  place.  On  the  other  hand,  gonorrheal  peritonitis  the 
result  of  a  septicemia  is  much  more  often  observed  in  children  than 
among  adults.  Gonorrheal  peritonitis  may  be  acute  or  subacute  from 
the  onset.  The  mode  of  infection  of  the  peritoneum  is  somewhat  doubt- 
ful. A  certain  proportion  of  cases  are  complicated  by  tubal  lesions, 
and  in  these  the  route  of  infection  can  easily  be  demonstrated.  It 
is  believed  that  general  peritonitis  occurs  so  frequently  in  these  cases 
because  the  peritoneum  of  children  is  more  receptive  to  infection  than 
is  that  of  the  adult,  and  a  salpingitis,  that  in  a  woman  would  lead 
only  to  a  pelvic  peritonitis,  and  that  would  quickly  become  localized, 
will,  in  a  young  child,  often  result  in  a  general  involvement  of  the 
entire  peritoneum.  Pyemia  is  also  more  frequent  in  infancy  and  child- 
hood. Systemic  infection  must  be  taken  into  consideratiomn  studying 
these  cases,  as  not  a  few  operations  and  autopsies  have  been  per- 
formed on  children  in  which  macroscopically  the  uterus  and  adnexa 
have  been  found  normal,  the  infection  in  these  cases  undoubtedly  hav- 
ing occurred  along  routes  similar  to  those  involved  in  arthritis  or  in 
endocarditis. 

Symptoms. — The  onset  of  peritonitig  is  generally  abrupt.  The 
temperature  rises  rapidly  to  101°  to  103°  F.  or  higher.  The  pulse 
and  respiration  are  rapid.  The  abdomen  is  distended  and  tender. 
The  bowels  are  usually  constipated,  but  in  rare  cases  diarrhea 
may  be  present.  The  pain  is  severe  and  often  paroxysmal  in  type. 
The  child  is  fretfid  and  refuses  nourishment.  The  extremities  are 
cold,  the  face  is  cyanosed,  and  the  facies  abdominalis  may  be  observed. 
Vomiting  and  tympanites  may  be  pronounced  symptoms.  If  the 
condition  is  chronic,  loss  of  weight,  anemia,  sleeplessness,  and  other 
evidences  of  severe  illness  become  manifest.  In  those  cases  in  which 
there  is  adnexal  involvement  the  greatest  tenderness  and  pain  occur 
over  these  regions. 

Dysuria,  painful  defecation,  and  general  malaise  are  usually 
present,  together  with  leukocytosis  and  other  evidences  of  peritonitis. 

Arthritis  is  not  infrequent.  In  35  cases  of  subacute  or  chronic 
peritonitis  studied  by  Galvagno'  there  was  a  mortality  of  20  per 
cent.  Carpenter-  states  that  even  in  cases  where  massive  pathology 
is  present,  spontaneous  recovery  may  result.  In  young  children  the 
pelvic  localization  of  gonorrheal  peritonitis,  even  when  of  tubal  origin, 
is  markedly  less  than  in  the  adult,  and,  as  a  result,  general  peritonitis 
is  relatively  more  frequent. 

Diagnosis. — The  diagnosis  is  dependent  on  the  symptoms  just  de- 

'  Galvagno:  Arch,  di  Patolog.  e  Clin.  Infant.,  1904,  vol.  ii,  Nos.  3,  4,  p.  7.3. 
-  Carpenter,  G.:  Brit.  Jour.  Child.  Diseases,  October,  1904,  p.  437. 


1 


GONORRHEA  IX  THE  EXTREMES  OF  LIFE  387 

scribed,  combined  with  the  presence  of  a  ^'ulvovaginitis  in  the  dis- 
charge from  which  gonococci  can  be  demonstrated.  It  is  important 
that  appendicitis,  intussusception,  volvulus,  and  other  acute  abdominal 
lesions  be  excluded.  This  can  usually  be  done  with  certainty  by  a 
careful  study  of  the  case.  Hatfield^  Baginsky,^  Mejia,^  Hunner  and 
Harris''  (3  cases),  Dowd,^  Welt-Kakels,^  Galvagno"  (3  cases),  Sebilleau* 
(3  cases),  Northrup^  (2  cases),  Bidwell,^"  Carpenter,'^  Comby'^  (8 
cases),  Marx,"  Koplik^^  (16  cases),  and  others  report  cases  of  pelvic 
or  general  peritonitis  of  gonorrheal  origin. 

Treatment. — The  treatment  of  gonorrheal  peritonitis  in  children 
is  similar  to  that  of  adults.  Especial  effort  should  be  made  to 
avoid  operating  during  the  acute  stage,  not  only  because  abdominal 
sections  among  infants  and  young  children  are  accompanied  by  a 
comparatively  high  mortality,  but  also  because  these  patients  seem 
peculiarly  amenable  to  the  palliative  treatment,  and  complete  cures 
by  this  method  are  often  effected. 

The  various  other  complications  that  occur  as  a  result  of  gonorrheal 
vulvovaginitis  in  children  are  pyemia,  endocarditis  or  pericarditis, 
proctitis,  stomatitis,  rhinitis,  and  ophthalmia.  These  will  be  de- 
scribed in  the  chapter  on  the  Complications  of  Gonorrhea. 

GONORRHEA  IN  THE  AGED 
Active  gonorrhea  in  women  past  fifty  years  of  age  is  infrequent. 
At  this  period  the  sexual  life  of  the  individual  is  on  the  wane,  men- 
struation has  ceased,  and  in  many  cases  the  menopause  has  been 
established.  In  this  connection,  however,  it  should  be  remembered 
that  women  vary  widely.  In  some  the  sexual  life  and  even  menstrua- 
tion are  continued  much  longer  than  in  others.  The  occurrence  of 
pregnancy  after  forty-five  is  infrequent, *°  and  when  the  menopause 

'  Hatfield,  M.  P.:  Arch,  of  Pcd.,  188G. 

'  Baginsky:  Lehrb.  der  Kinderkrankheitcn,  1902. 

'  Mejia:  .Abst.  Central,  f.  allgein.  Path,  u.  pathol.  Anat.,  li)OI,  vol.  xii. 

*  Hunner  and  Harris:   Bull.  .Johii.s  H()])kin.s  Hosp.,  1002. 

'  Dowd:   Ann.  Surg.,  Februarj',  1902. 

'  Welt-KakoLs,  S.:  New  York  Med.  Jour,  and  Phila.  Med.  Jour.,  Oetober  29,  1901. 

( ialvagno,  P.:  Aroh.  di  Patol.  c  Clin.  Infant.,  1904. 
"  Sebilleau:  (lazotto  de.s  II6pitaux,  March  8,  1904,  p.  201. 
»  Northnip,  \V.:  Arrh.  of  Ped.,  1903,  No.  12,  p.  910. 
'»  Bidwell,  L.  A.:   Brit,  Jour.  Children's  Dis.,  1904,  vol.  I,  p.  43.5. 
"  Carpenter,  ().:   Brit.  Jour.  Children's  Dis.,  1904,  vol.  i,  p.  437. 
"  Coniby,  J.:  -Arch,  de  nied.  dcs  enfanls,  September,  1901,  p.  o\'). 
"Marx:   Med.  Ree.,  January,  189(5. 
'*  Koplik:   Dis.  of  Infancy  and  Childhooil,  3d  ed. 

"  Norris,  Charles  C.:  Jour,  .\nier.  Med.  A.s.soe.,  .April  22,  1911;  also  Anier.  Jour.  Obst., 
1910,  vol.  Ixi,  No.  2. 


3g8  GONORRHEA   IN   WOMEN 

has  been  established,  the  Ukehhood  of  gonorrhea  spreading  above  the 
cervix  is  extremely  improbable,  unless  intra-uterine  manipulations 
are  performed.  As  has  frequently  been  stated,  the  time  at  which 
gonorrhea  is  most  prone  to  extend  above  the  cervix  is  either  at  a 
menstrual  period  or  following  the  emptying  of  a  pregnant  uterus. 
As  menstruation  and  pregnancy  are  absent  in  the  aged,  extension  of 
gonorrheal  cervicitis  is  unlikely. 

As  a  further  cause  for  infrequency  of  active  gonorrhea  at  this 
period  the  physiologic  changes  that  are  occurring  throughout  the 
genital  tract  must  be  considered.  All  the  structures  usually  attacked 
by  the  gonococcus  are  beginning  to  undergo  atrophy,  and  the  blood- 
supply  of  the  various  organs  is  diminished.  In  addition,  the  likehhood 
of  contracting  a  primary  gonorrhea  at  this  time  is  much  lessened. 
Promiscuous  sexual  intercourse  is  certainly  uncommon  at  this  age, 
and  the  probability  of  a  husband  becoming  infected  and  thus  con- 
taminating his  wife  is  likewise  lessened. 

The  lesions  produced  by  the  gonococcus  have  been  described  in 
previous  chapters.  Many  women  of  forty  years  suffer  from  gonorrhea, 
and  are  not  operated  upon  or  even  treated  during  the  succeeding  ten 
years.  What,  then,  becomes  of  the  gonococcus  in  these  cases?  It 
would  seem  that,  as  a  result  of  the  physiologic  changes  already  in- 
dicated, the  microorganism  first  becomes  innocuous  and  later  perishes. 
This  conclusion  has  been  reached  by  a  study  of  the  clinical  material 
alone.  Of  the  last  125  cases  of  pelvic  inflammatory  disease  operated 
upon  in  the  (gynecologic  Department  of  the  University  of  Pennsyl- 
vania, the  oldest  patient  was  forty-seven  years  of  age,  and  the  average 
age  was  29.9  years.  The  following  table  shows  the  age  in  five-year 
periods  at  which  the  various  patients  were  operated  upon : 

Number  of  Cases  Per  Cent. 

15  to  20  years 2  1.6 

20  "  25     "     38  30.4 

25  "  30     "     31  24.8 

30  "  35     "     16  12.8 

35  "  40     "     19  15.2 

40  "  45     "     13  10.4 

45  "  47     "     6  4.8 

Active  gonorrhea  of  the  lower  genital  tract  in  the  aged  is  extremely 
uncommon — far  more  so  than  is  a  corresponding  condition  in  the  male. 
This  may  largely  be  accounted  for  by  the  longer  sexual  life  in  the 
latter.  The  fact  that  even  intraperitoneal  gonorrhea  is  rarely  trouble- 
some after  the  establishment  of  the  menopause  should  be  taken  into 
consideration  in  treating  cases  of  pelvic  inflammatory  disease  that 
are  approaching  this  period  of  life.     This  should  not,  however,  be 


i 


GONORRHEA    IN    THE    EXTREMES    OF    LIFE  389 

allowed  to  overrule  the  clinical  judgment  of  the  gynecologist  in  treat- 
ing these  patients.  It  must  be  remembered  that  although  relatively 
few  cases  of  pelvic  inflammatory  disease  are  operated  upon  after  the 
menopause,  practically  all  severe  cases  are  acquired  much  earlier 
in  life,  and  are,  therefore,  operated  upon  early  or  receive  curative 
treatment,  so  that  comparatively  few  severe  lesions  are  found  at  this 
period  of  life. 


CHAPTER  XVII 

COMPLICATIONS  AND  NON-GENITAL  GONORRHEA.— CYSTITIS.— 
ADENniS.— PROCTITIS.— STOMATITIS.— RHINITIS.— OPH- 
THALMIA IN  INFANTS,  YOUNG  GIRLS,  AND  ADULTS 

GONORRHEAL  CYSTITIS 

This  is  a  comparatively  frequent  complication  of  gonorrhea 
of  the  lower  genital  tract,  and  is  usually  a  consequence  of  an  ex- 
tension backward  of  an  inflammation  of  the  urethra.  Catheteriza- 
tion or  other  instrumentation  in  cases  of  gonorrheal  urethritis  may 
result  in  carrying  the  infection  to  the  bladder,  and  in  this  way  also 
a  cystitis  may  be  produced.  In  rare  cases,  perhaps,  cystitis  may  result 
from  a  systemic  or  renal  infection,  but  this  is  doubtful.  In  many 
instances  the  gonococcus  is  present  in  combination  with  other 
microorganisms,  such  as  the  streptococcus,  staphylococcus.  Bacillus 
coli,  or  other  pyogenic  cocci. 

The  earlier  writers  believed  that  gonorrheal  cystitis  was  always 
the  result  of  a  mixed  infection,  but  the  works  of  Wertheim^  and 
Young^  have  amply  proved  the  fallacy  of  this  supposition.  Melchoir' 
was  probably  the  first  to  recover  the  gonococcus  from  the  urine  in  a 
case  of  acute  cystitis  under  conditions  that  would  fairly  exclude  the 
possibility  of  urethral  contamination.  Unfortunately,  his  results 
were  not  confirmed  by  culture,  and  to  Wertheim^  belongs  the  credit 
of  having  absolutely  demonstrated  these  organisms  from  an  acute 
case.  His  report  was  followed  shortly  by  that  of  Lindholm,^  with 
similar  results.  Young"  was  the  first  to  demonstrate  gonococci  in 
pure  cutlure  hi  a  chronic  case.  In  some  of  Young's  cases  the  urine 
was  obtained  by  suprapubic  aspiration,  thus  positively  excluding 
the  possibility  of  urethral  contamination.  In  Wertheim's  case, 
however,  a  piece  of  bladder-wall  was  excised  through  a  cystoscope, 
and  gonococci  found  within  the  tissue,  whereas  in  the  other  cases 
mentioned  cystitis  was  demonstrated  by  the  cystoscope.  Gonococci 
from  the  bladder  are  difficult  to  cultivate,  owing  to  the  fact  that 

'  Wertheim:  Zeit.  f.  Geb.  u.  Gyn.,  vol.  xxxv,  No.  1,  p.  1. 

-  Young,  H.  H.:  Contributions  to  the  Science  of  Medicine,  Baltimore,  1900,  p.  677. 

^  Melchoir,  M.:  Cystite  et  Infection  Urinaire,  P.aris,  1895. 

*  Wertheim:  Zeit.  f.  Geb.  u.  Gyn.,  vol.  xxxv,  No.  1,  p.  1. 

*  Lindholm:  Lyon  Med.,  November  15,  1896. 

'  Young,  H.  H.:  Contributions  to  the  Science  of  Medicine,  Baltimore,  1900,  p.  677. 
390 


COMPLICATIONS    AND    XOX-GEXITAL    GONORRHEA  391 

unless  the  urine  contains  considerable  albumin  the  gonococci  do  not 
thrive.  It  may  partially  be  due  to  this  fact  that  gonococcal  cystitis 
is  not  more  frequent,  especially  in  women.  Young'  has  also  shown 
that  in  rare  instances  gonococci  may  be  present  in  the  bladder  with- 
out producing  an  inflammation. 

In  long-standing,  chronic  cases  the  possibility  of  a  tuberculosis 
being  superimposed  upon  the  original  Neisserian  infection  should  be 
considered.  Kiimmell^  has  reported  a  number  of  such  cases.  Tuber- 
culosis of  the  bladder  unassociated  with  renal  tuberculosis  is,  however, 
uncommon.  Predisposing  causes  are  not  necessary  to  the  production 
of  gonorrheal  cystitis.  Factors  that  lower  the  resistance  of  the  vesical 
mucosa,  however,  favor  the  extension  of  infection  to  this  organ,  and 
act  unfavorably  during  the  course  of  the  disease.  The  chief  causes 
predisposing  to  cystitis  are,  therefore,  interference  with  the  blood- 
supply  of  the  bladder,  such  as  is  sometimes  produced  by  pressure  from 
a  neoplasm,  the  fetal  head,  or  a  vaginal  pessary,  chronic  congestion, 
as  in  uterine  displacements,  pregnancy,  excessive  coitus,  cold,  anemia, 
overdistention  of  the  bladder,  vesical  calculi,  irritating  drugs,  cys- 
tocele,  debility,  wasting  diseases,  trauma,  and  vesical  tumors.  Peri- 
cystitic  inflammatory  disease, .  such  as  gonorrheal  lesions  of  the 
tubes,  ovaries,  or  body  of  the  uterus,  may  be  contributing  factors 
in  the  production  of  cystitis,  not  only  by  causing  congestion,  but 
as  the  result  of  a  direct  infection  through  the  bladder-wall.  In 
gonorrheal  cystitis,  however,  the  latter  is  of  rare  occurrence,  the 
cystitis  usually  being  the  result  of  an  original  urethritis. 

The  trigone  is  the  area  first  infected.  The  inflammation  may 
remain  localized  in  this  region,  or  may  spread  to  the  entire  vesical  mu- 
cosa. Trigonitis  is  much  more  frequent  than  cystitis,  and  this  is  the 
locality  in  which  the  disease  is  most  resistant  to  treatment.  Knorr' 
states  that  extension  from  the  urethra  to  the  bladder  is  most  likely 
to  occur  during  the  acute  stage  of  the  infection,  but  that  a  trigonitis 
or  cystitis  may  result  from  a  latent  urethritis.  Owing  to  the  short- 
ness of  the  urethra,  women  arc  more  frequently  the  incumbents  of 
gonorrheal  cystitis  than  men.  Barlow'  has  reported  cases  of  this 
condition  occurring  in  infants  and  young  children. 

Symptoms. — The  di.sease  may  begin  as  an  acute  attack,  or  may 
be  subacute  from  the  onset.  During  the  acute  stage  the  symptoms 
are  generally  marked.     Urination  is  frequent,  imperative,  and  pain- 

'  'S'oniiK,  II.  II.:   .loliiLs  Hopkin.s  Ho.spiliil  Ucporls,  vol.  ix,  p.  077. 

-'  Kiiiniiicll,  H.:  Surg.,  Gyn.,  and  Oh.st.,  .\pril,  1911. 

■'  Knorr,  R.:  Zpitsclir.  f.jjyniik.  I'rol.,  Loipzin,  Kobruiiry,  I'.UO,  vol.  ii.  p  .")4. 

'  Mill-low:    .Vrcli.  f.  ncnii;it..  ISiCJ. 


392  GONORRHEA    IN    WOMEN 

ful;  ardor  urinse  and  tenesmus  are  often  prominent  symptoms.  The 
pain  is  usually  relieved  after  emptying  the  bladder,  but  in  some  cases 
may  continue.  There  is,  as  a  rule,  a  feeling  of  fulness  and  weight 
in  the  pelvis,  and  if  the  patient  attempts  to  retain  her  urine,  sharp, 
cutting  pains  in  the  region  of  the  anus  and  rectum  may  occur.  Rectal 
tenesmus  may  also  be  present.  Constitutional  symptoms  are  not, 
as  a  rule,  severe.  Slight  fever,  malaise,  headache,  and  loss  of  appetite 
may  be  present  for  a  few  days  at  the  onset  or  during  the  height  of  the 
attack.  The  systemic  symptoms  usually  disappear  in  a  short  time 
without  treatment.  The  urine  is  generally  acid  and  cloudy,  and 
contains  blood,  vesical  epithelium,  pus,  mucus,  or  uric  acid.  It  may 
be  alkaline.  Tenderness  is  present  over  the  bladder  and  urethra, 
and  inspection  of  the  latter  reveals  the  characteristic  appearance 
seen  in  infections  of  this  region.  Evidences  of  gonorrhea  can  usually 
be  detected  in  the  cervix  and  often  in  Bartholin's  glands.  The  urine 
contains  gonococci,  which  may  be  demonstrated  by  the  method 
previously  described.  (See  page  59.)  Care  must,  however,  be 
observed  that  urethral  contaminations  do  not  occur,  and  even  the 
most  painstaking  technic  is  imperfect  unless  a  cystoscopic  examina- 
tion is  performed,  and  the  diagnosis  is  confirmed  by  inspection  as 
well  as  by  the  result  of  examination  of  specimens  obtained  direct  from 
the  diseased  area.  In  some  cases  confrontation  is  possible,  but  this 
is  of  little  value  except  so  far  as  it  reveals  the  variety  of  the  original 
infection. 

WTien  the  disease  becomes  chronic,  the  same  general  symptoms 
are  present,  but  in  a  less  aggravated  form.  With  the  aid  of  the 
cystoscope  the  diagnosis  of  cystitis  or  trigonitis  is  not  difficult  at 
this  stage,  but  the  determination  of  the  microorganism  productive  of 
the  condition  is  frequently  not  so  easy.  It  seems  hardly  necessary  to 
state  that  the  cystoscope  should  not  be  employed  indiscriminately  dur- 
ing the  acute  stage  of  either  a  gonorrheal  cystitis  or  in  the  presence  of 
an  acute  urethritis.  Careful  modern  bacteriologic  methods  will,  how- 
ever, clear  up  any  doubt  that  may  exist  as  to  the  etiology  of  the  condi- 
tion. The  acid  urine,  the  presence  of  gonorrhea  in  Skene's  glands  and  in 
the  lower  genital  tract,  together  with  the  history  that  usually  accom- 
panies such  cases,  are  factors  pointing  toward  the  gonorrheal  origin 
of  the  inflammation.  Cystoscopic  examination  shows  the  vesical 
mucosa  to  be  reddened,  thickened,  and  inflamed.  The  congestion 
is  generally  most  marked  at  the  trigonum.  In  some  cases  ulcers  may 
be  present;  these  may  bleed  spontaneously  or  on  the  slightest  touch, 
or  they  may  be  sluggish  in  type.  Areas  of  granulation  tissue  may  be 
observed,  partially  or  entirely  covered  by  pus  or  a  deposit  of  cellular 


COMPLICATIONS    AND    NON-GENITAL    GONORRHEA  393 

debris  and  urinary  salts.  Ulcers  on  the  vertex  are  less  apt  to  cause 
severe  symptoms  than  when  situated  on  the  base,  and  may  produce 
discomfort  only  when  the  bladder  is  full;  on  the  other  hand,  when 
situated  on  the  floor  of  the  bladder,  the  raw  area  is  constantly  brought 
into  contact  with  the  mine,  and  also,  on  account  of  the  more  abundant 
nerve-supply  of  this  portion  of  the  bladder,  these  ulcers  are  productive 
of  greater  pain.  Ulcers  at  the  trigonum  are  often  characterized  by 
tenesmus,  and  urination  is  frequently  accompanied  by  the  passage  of 
varying  amounts  of  blood. 

Treatment. — During  the  acute  stage  the  patient  should  be  kept 
in  bed  and  the  bowels  regulated.  The  diet  should  be  restricted,  and 
should  consist,  as  nearly  as  possible,  of  milk;  diluent  drinks  are  in- 
dicated, and  all  alcohol  should  be  interdicted.  Salol  and  urotropin 
in  5-  to  "-grain  doses  should  be  given  every  six  hours.  A  good  plan  is 
to  administer  the  salol  and  follow  it  in  three  hours  by  the  urotropin, 
a  large  glass  of  water  being  taken  with  each  dose.  A  half-pint  of 
water  is  thus  given  every  three  hours.  In  this  connection  it  is  im- 
portant to  bear  in  mind  that  Burnam's  test  has  shown  that  in  .50  per 
cent,  of  patients  taking  urotropin  formaldehyd  does  not  appear  in  the 
urine.  This  result  has  been  confirmed  by  L'Esperance  and  Cabot.' 
This  fact  is  apparently  not  influenced  by  the  amount  of  urotropin 
administered.  The  urine  should,  therefore,  be  examined  for  formalde- 
hyd in  all  cases.  Hexamethylenamin  usually  gives  excellent  results, 
provided  the  urine  is  acid.  Jordan-  has  shown  that  the  liberation  of 
formaldehyd  occurs  to  only  a  limited  extent  if  the  reaction  is  alkaline, 
and  not  at  all  in  the  presence  of  free  ammonia.  Hot  hip-baths  are 
often  comforting  to  the  patient,  and  if  the  pain  is  severe,  morphin 
may  be  required.  The  external  genitalia  should  be  kept  clean  by 
frequent  irrigations  of  sterile  water,  l)ichlorid  1:12,000,  or  other  weak 
antiseptic  solutions.  An  irrigation  of  the  external  genitalia  should 
follow  each  urination,  the  best  method  being  to  have  a  large  irrigating 
apparatus  constantly  beside  the  ])atient's  bed.  .\  sterile  dressing 
should  be  placed  over  the  vulva. 

During  the  chronic  stage  of  cystitis  local  tn^atment  should  be  in- 
stituted. This  consists  of  irrigating  the  bladder  once  or  twice  daily 
with  sterile  water  or  normal  salt  solution,  or,  best  of  all,  a  weak  sil- 
ver nitrate  solution,  1:5000  to  1:.500.  In  applying  the  irrigation,  the 
bladder  should  be  distended  sufficiently  to  allow  the  solution  to  reach 
all  parts  of  the  mucosa.     The  irrigation  should  be  followed  by  the  in- 

'  L'E.sporiincc,  O.  H.  T.,  and  Cabot,  II.:  Bo.stnii  Mcil.  and  Siirn.  .Ii.iir.,  OcIoIkt  '.M, 
I'.Mi. 


■■.Itirdaii.  A.:    UlicImim.  .Iciir  ,  I'.lll,  vol.  v,  p.  274. 


\1^ 


394  GONORRHEA    IN    WOMEN 

stillation  of  some  mild  antiseptic,  one  of  the  most  satisfactory  of  which 
is  a  95  per  cent,  solution  of  silver  iodid  suspended  in  mucilage  of  acacia 
or  Irish  moss.  Ulcers  on  the  vesical  mucosa  are  best  treated  by- 
direct  applications  made  through  the  cystoscope,  silver  nitrate,  in  5 
to  20  per  cent,  solution,  being  the  most  satisfactory  application,  the 
strength  of  the  solution  being  reduced  as  the  ulcers  heal.  Dilatation 
of  the  urethra  to  20  mm.  is  often  beneficial  in  obstinate  cases,  while 
continuous  drainage  with  a  mushroom-tipped  soft  catheter  may,  in 
some  cases,  be  employed  with  advantage.  When  the  latter  mode  of 
treatment  is  adopted,  the  catheter  should  be  changed  every  two  or  three 
days,  and  every  effort  made  to  keep  it  clean  while  in  place.  In  very 
persistent  cases  the  formation  of  a  vesicovaginal  fistula,  for  the 
purpose  of  allowing  the  bladder  to  rest  and  producing  constant  drain- 
age, may  be  necessary.    ■ 

LYMPHADENITIS 

Lymphadenitis  of  the  inguinal  glands,  although  a  frequent  com- 
plication of  gonorrhea  in  the  male,  is  comparatively  infrequent  in 
the  female.  In  women  the  inflammation  rarely  progresses  to  the 
suppurative  stage.  A  low-grade  adenitis  is  occasionally  encountered 
as  a  complication  of  gonorrhea  of  the  lower  genital  tract,  or  pelvic 
inflammatory  disease,  which  manifests  itself  by  slight  pain  or  tender- 
ness in  the  inguinal  regions  at  and  for  a  few  days  preceding  menstrua- 
tion. At  these 'periods  the  glands  on  one  or,  more  rarely,  on  both 
sides  are  somewhat  enlarged  and  sensitive.  The  subjective  symptoms 
disappear  in  a  few  days.  In  some  instances  the  glands  may  be  en- 
larged and  somewhat  tender  between  the  menstrual  periods,  but  this 
is  uncommon.  This  condition,  as  a  rule,  requires  no  treatment. 
During  pregnancy,  the  puerperium,  and  as  a  complication  of  vulvo- 
vaginitis in  childhood  adenitis  is  more  frequent,  but  even  at  such 
times  it  is  seldom  encountered.  The  treatment  during  the  early 
stages  consists  in  the  application  of  cold  and  free  incision  and  drainage 
if  pus  is  formed. 

Adenitis  in  other  areas  is  a  rare  condition.  In  1896  Petit  and 
Pichevin^  recorded  the  history  of  a  case  in  which  gonococci  were 
recovered  in  pure  culture  from  an  adenitis  of  the  glands  of  the  neck. 
This  is  the  first  case  from  which  gonococci  have  been  demonstrated 
in  pure  culture  from  lymphatic  glands  other  than  the  inguinal  region. 
'  Petit  and  Pichevin:  Jour.  d.  Mai.  Cutan.  et  Syph.,  Paris,  1S96,  p.  419. 


COMPLICATIONS    AND    NON-GENITAL    GONORRHEA  395 

PROCTITIS 

Jesionek^  was  the  first  to  cultivate  the  gonococcus  from  the 
mucosa  of  the  rectum,  and  thus  absolutely  establish  the  identity 
of  this  condition. 

Gonorrheal  proctitis  is  more  frequent  in  women  than  in  men,  be- 
cause of  the  closer  anatomic  relationship  that  exists  in  the  former 
between  the  genito-urinary  organs  and  the  rectum,  and  that  allows 
gonococci-bearing  discharges  from  the  vagina  to  escape  over  the 
perineum  and  anus.  Proctitis  is  seldom  encountered,  even  among 
women.  In  this  country  the  disease  is  most  frequently  met  with 
among  low-class  foreigners,  and  is  often  due  to  the  practice  of  sodomy. 
Baer^  states  that  infection  of  the  rectum  occurs  in  30  per  cent,  of  all 
female  gonorrheics,  while  Huber'  places  the  proportion  at  25  per  cent. 
Both  these  figures  are,  the  author  believes,  much  too  high.  Jullien^ 
collected  the  statistics  of  Schultz,  Baer,  and  Howard,  which  com- 
prised 1037  cases  of  genital  gonorrhea  in  women;  in  this  series  157 
showed  rectal  involvement. 

Proctitis  is  more  often  met  with  in  young  children  as  the  result 
of  vulvovaginitis  than  in  adults.  The  condition  may  be  either  a 
primary  infection  of  the  rectum  or  secondarj^  to  gonorrhea  of  other 
organs.  Primary  gonorrheal  proctitis  may  result  from  coitus  per  anus 
or  from  contamination  of  the  rectum  by  a  septic  rectal  examination, 
instrumentation,  or  operation,  an  infected  syringe  nozle,  or  an  enema 
tube.  In  infants  the  condition  may  result  from  contamination  of  the 
rectum  during  the  passage  of  the  child  through  the  birth-canal.  Sec- 
ondary proctitis  is  the  variety  most  frequently  observed.  That  this 
condition  is  not  more  prevalent  can  be  explained  by  the  fact  that  the 
sphincter  is  usually  tightly  contracted,  and  that  the  structures  external 
to  it  are  covered  by  squamous  epithelium,  a  type  of  tissue  in  which 
the  gonococcus  never  flourishes.  Lockyer*  asserts  that  direct  con- 
tact of  the  gonorrheal  discharge  with  the  deeper  parts  of  the  anal  canal 
is  necessary  for  infection.  The  fre(iuency  with  which  the  perineum 
and  anus  are  soiled  with  gonococci-bearing  leukorrheal  discharges, 
and  the  comparative  infrecjuency  of  involvement  of  tlie  rectum,  are 
proofs  in  themselves  of  the  correctness  of  the  foregoing  statement, 
(lonorrheal  proctitis  may  in  rare  instances  be  caused  by  a  direct 
infection  from  an  adherent  uterine  appendage.     The  author  has  seen 

'  .Jesionck,  A.:    Dent.  Arcli.  f.  klin.  Mod.,  L;'ip/,ig,  1898,  vol.  Ixi,  p.  'Jl. 
•  Baer:    Dcut.  iiicil.  Wofhcnsclii-.,  ISiKi,  vol.  xxii,  p.  llt'>. 
'  HuIkt:   Arch.  f.  D<Tmal.  u.  Sjph.,  1807,  vol.  xl,  p.  2:17. 
'.hillicn:  Bull.  <le  I'Acud.  ile  Mc'd.,  Paris,  1907,  vol  l.xxi,  p  497. 
Lockycr:   Quoted  by  Zobcl,  A.  J.:    Thc>  Proctologist,  1909,  vol.  iii,  p.  ISS. 


396  GONORRHEA    IN    WOMEN 

three  cases  resulting  from  the  rupture  of  a  pyosalpinx  into  the  rectum. 
Proctitis  resulting  from  a  tubo-intestinal  fistula  is  likely  to  be  ex- 
tremely chronic,  owing  to  constant  reinfection.  In  all  cases  of  proctitis 
in  women  a  thorough  pelvic  examination  should  be  made,  as  in  most 
cases  the  disease  is  secondary  to  gonorrhea  of  the  genital  tract.  Sys- 
temic infection  is  not  impossible. 

Symptoms. — These  vary  widely  in  different  cases  and  during  the 
various  stages  of  the  disease.  At  the  onset  there  are  usually  heat, 
itching,  and  a  feeling  of  fulness  about  the  anus  and  lower  rectum, 
which  rapidly  progress,  and  pain  soon  becomes  a  prominent  symptom. 
It  is  excruciating  during  defecation,  and  as  a  result  the  patient  often 
permits  herself  to  become  constipated.  Tenesmus  is  almost  invariably 
a  marked  feature.  This  symptom  can  often  be  elicited  by  having  the 
patient  strain  or  tightly  contract  the  sphincter.  Palpation  of  the 
affected  areas  causes  severe  pain.  The  soreness  about  the  rectum 
is  augmented  by  walking,  and  is  relieved  by  rest  in  the  recumbent 
posture.  The  lowermost  portion  of  the  intestine  is  almost  invariably 
primarily  involved,  and,  as  a  consequence,  during  the  early  stages  of 
the  infection  it  is  in  this  locality  that  the  symptoms  are  most  marked. 
The  patients  usually  complain  of  a  feeling  of  heat,  weight,  and  dis- 
comfort about  the  pelvis.  Irritability  of  the  bladder  may  be  present. 
Moderate  pyrexia  and  its  accompanying  phenomena  are  usually 
associated  with  proctitis.  As  the  disease  becomes  more  chronic  the 
severity  of  the  symptoms  is  somewhat  lessened;  the  patient  may  be 
weak,  look  haggard,  and  feel  feverish.  In  some  cases  the  symptoms 
are  extremely  mild.  During  the  acute  stage  the  discharge  consists 
of  yellowish  pus,  but  later  it  may  become  thin.  It  is  frequently 
blood-stained.  According  to  McVeigh,^  in  severe  or  neglected  cases 
bleeding  may  be  a  pronounced  symptom. 

Examination  generally  reveals  an  exanthematous  condition  of 
the  peri-anal  region,  and  the  eruption  may  extend  to  the  thigh,  peri- 
neum, and  buttocks.  The  cutaneous  surface  is  covered  with  a  moist, 
more  or  less  purulent,  secretion.  Condylomatous  growths  are  often 
present,  and  are  similar  to  those  observed  in  gonorrhea  of  the  genital 
tract.  Fissures  are  often  present.  The  most  frequent  location  for  a 
fissure  is  in  the  posterior  anal  border.  It  is  often  partially  covered 
by  a  venereal  wart,  and  can  sometimes  be  demonstrated  only  by 
pushing  the  latter  aside.     Strictures  may  result. 

Small  furuncles  may  be  seen  about  the  anus  and  in  the  anal  and 
gluteal  folds.  If  the  infection  is  the  result  of  sodomistic  practices,  the 
anus  is  often  depressed — the  so-called  funnel-shaped  anus.     During 

'  McVeigh:  The  Proctologist,  September,  1912,  p.  172. 


COMPLICATIONS    AND    NON-GENITAL    GONORRHEA  397 

the  acute  stage  instrumental  or  digital  examination  is  often  impossible 
without  the  aid  of  an  anesthetic,  on  account  of  the  sensitiveness  of 
the  rectum.  In  neglected  or  long-standing  cases  fissures  may  de- 
velop about  the  anus,  producing  marked  redness  and  infiltration  of 
the  mucosa.  Ulcers  are  not  uncommon.  In  some  individuals  the 
sphincter  is  relaxed,  and  on  straining  the  mucosa  of  the  rectum 
may  be  brought  into  view.  As  the  result  of  edema  a  partial  pro- 
lapse may  take  place,  somewhat  similar  to  the  chemosis  encoun- 
tered in  acute  inflammation  of  the  conjunctiva.  A  cicatrix  may  be 
present  in  the  rectum  or  sphincter,  and  perirectal  abscesses  may  result. 

Jadassohn*  beUeves  the  latter  to  be  a  not  infrequent  complication 
of  proctitis.  Complications,  such  as  arthritis  or  endocarditis,  may 
occur.  As  a  general  rule  the  disease  is  confined  to  the  lower  3  or  4 
inches  of  the  rectum,  but  in  severe  cases  more  extensive  involvement 
is  not  uncommon.  In  chronic  cases  a  curiously  depressing  effect, 
resembling  neurasthenia,  .similar  to  that  sometimes  produced  by  a 
posterior  urethritis  in  the  male,  is  occasionally  observed.  In  infants, 
during  the  early  stage,  the  condition  may  somewhat  simulate  the  more 
frequent  intestinal  disorders  resulting  from  improper  feeding. 

The  diagnosis  of  gonorrheal  proctitis  depends  upon  the  demonstra- 
tion of  the  specific  microorganism  in  the  discharge.  In  this  connec- 
tion it  is  important  to  remember  that  when  a  positive  diagnosis  is 
desirable,  the  Micrococcus  catarrhalis  and  other  microorganisms  that 
are  morphologically  similar  to  the  gonococcus,  and  which  may  be 
found  in  the  alimentary  tract,  must  be  excluded.  The  presence  of 
gonorrhea  in  the  genito-urinary  tract,  the  history  of  the  case,  the 
presence  of  a  funnel-shaped  anus,  and  the  absence  of  other  etiologic 
factors  are  points  that  should  put  the  physician  on  his  guard  for  this 
type  of  infection.  Wiener-  has  reported  a  case  with  secondary 
parenchymatous  nephritis. 

Treatment. — Not  infrequently,  during  the  acute  stage,  on  account 
of  the  exquisite  sensitiveness  of  the  affected  area,  the  employment 
of  intrarectal  applications  are  impossible.  Cleanliness  is  at  all  times 
of  paramount  importance.  The  peri-anal  region  should  be  frequently 
washed  with  warm  water  and  Castile  soap,  then  dri(>il,  and  a  dusting- 
powder,  such  as  zinc  .stearate  or  boric  acid,  applied.  In  some  cases 
where  the  dermatitis  is  severe  applications  of  sweet  oil  are  beneficial. 

.\  pad  of  absorbent  cotton  should  be  worn  i)etween  the  buttocks, 
and  over  all  a  sterile  gauze  dressing  should  l)e  jilaced.  .Vs  in  treating 
vulvitis,  every  effort  should  be  made  to  keep  the  affected  areas  dry 

'  .Jiuliussohn:   Dciil,  Kliiiik,  liiilin,  I'JO.'.,  vol,  \,  pp.  (>01-(i(iO. 
-  Wiener,  K.:  Med.  Klin.,  Berlin,  li»12,  vol.  viii,  p.  1029. 


398  GONORRHEA    IN    WOMEN 

and  clean.  A  laxative,  preferably  a  saline  aperient,  should  be  ad- 
ministered. Hot  sitz-baths  are  often  beneficial  in  relieving  the  ten- 
esmus and  other  acute  symptoms.  As  soon  as  it  is  found  feasible, 
a  rectal  douche  of  sterile  water  should  be  administered  three  or  four 
times  daily.  For  this  purpose  ZobeP  recommends  one  dram  of 
sodium  bicarbonate  to  the  pint  of  warm  water.  This  may  be  given 
through  a  two-way  catheter.  This  solution  tends  to  remove  the 
secretion  that  is  adherent  to  the  rectal  mucosa.  As  a  further  treat- 
ment a  daily  application  of  one  of  the  milder  silver  salts  is  indicated. 
For  this  purpose  the  patient  should  be  placed  in  the  knee-chest  or 
elevated  Trendelenburg  posture,  and  the  peri-anal  region  wiped  clean 
with  cotton  moistened  in  some  antiseptic  solution.  A  small,  well- 
lubricated  proctoscope  or  a  small  Sims'  speculum  should  then  be 
inserted  into  the  rectum.  If  the  latter  instrument  is  employed,  it  is 
a  good  plan  to  use  the  gloved  finger  as  an  obturator.  After  an  inspec- 
tion of  the  rectum  has  been  made  and  the  lower  bowel  cleansed  as 
well  as  possible,  a  small  tampon  should  be  inserted  and  the  rectum 
irrigated.  A  solution  of  argyrol  (10  to  20  per  cent.)  or  silver  nitrate 
(0.25  to  1  per  cent.)  is  then  poured  in  through  the  speculum.  The 
tampon  benefits  not  only  by  smoothing  out  the  folds  of  the  rectal 
mucosa  and  thus  facilitating  the  treatment,  but  it  becomes  saturated 
with  the  solution,  and  in  this  way  enables  the  operator  to  applj^  the 
germicide  over  a  protracted  period.  If  small,  the  tampon  may  be 
left  in  place  and  will  be  passed  without  difficulty  at  the  first  bowel 
movement.  Ulcerations  of  the  rectum,  fistula,  or  other  complications 
should  also  be  treated  at  this  time.  If  gonorrhea  is  present  in  the 
genital  tract,  it  should  receive  appropriate  treatment.  This  is  espe- 
cially necessary  in  women,  in  whom  proctitis  is  usually  secondary  to 
gonorrhea  of  the  genital  tract. 

The  patient  had  best  be  kept  in  bed  during  the  acute  stage,  and, 
if  the  general  condition  permits,  receive  a  restricted  diet.  Albumin- 
water,  on  account  of  the  small  amount  of  ash  produced,  is  an  excellent 
diet  during  the  acute  stage.  Proctitis  is  frequently  extremely  chronic 
and  resistant  to  treatment.  Jullien-  mentions  treating  3  cases  of 
his  series  for  periods  of  one  hundred  and  sixteen,  one  hundred  and 
sixty-nine,  and  one  hundred  and  seventy-four  days  respectively. 

GONORRHEAL  STOMATITIS 
This  is  a  rare  variety  of  infection,  and  may  occur  in  infants  or 
in  adults,  and  is  probably  more  frequent  in  the  latter.     The  mouth 
'  Zobel,  A.  J.:  The  Proctologist,  1909,  vol.  iii,  p.  188. 
'  Jullien:  Bull,  de  I'Acad.  de  M6d.,  Paris,  1907,  vol.  Ixxi,  p.  497. 


COMPLICATIONS    AND    NON-GENITAL    GONORRHEA  399 

being  lined  by  squamous  epithelium,  is  a  poor  soil  for  the  develop- 
ment of  the  gonococcus  under  ordinary  conditions.  The  absence  of 
a  horny  layer  is,  however,  a  factor  that  favors  infection.  In  infants 
the  layer  of  squamous  epithelium  is  thin,  and,  as  a  result,  infection 
easily  occurs.  Koplik^  states  that  the  infection  is  favored  by  trauma 
of  the  mucosa.  It  is  likely  that  gonorrheal  stomatitis  in  infants  is 
more  common  than  is  generally  suspected,  and  the  gonococcal  factor 
is  probably  not  infrequenth'  overlooked.  In  infants  the  condition  is 
usually  produced  by  contamination  of  the  buccal  cavity  with  gonor- 
rheal discharges  during  the  passage  of  the  child's  head  through  the 
birth-canal.  It  is  not  infrequently  associated  with  a  specific  ophthalmia. 
Rosinski-  states  that  the  condition  is  much  more  frequent  in  infants 
than  in  adults.  He  reports  5  cases.  Krast^  and  Dohrn^  also  report 
cases.  Leyden=  records  a  case  of  gonorrheal  ophthalmia  neonatorum 
complicated  by  a  pustule  in  the  mouth  from  the  discharge  of  which 
gonococci  were  obtained.  Mixed  infection  is  probably  frequent. 
Jiirgens''  reports  a  case  in  which  the  bacillus  of  Vincent's  angina 
was  present.  The  glands  of  the  neck  on  the  right  side  were  swollen 
and  tender.  Gonococci  were  demonstrated  by  staining,  but  not  by 
culture  methods,  and  for  this  reason  the  diagnosis  is  open  to  doubt. 

The  disease  generally  becomes  manifest  in  two  or  three  days,  and, 
according  to  Rosinski,'  is  not  accompanied  by  constitutional  sj^mptoms. 
Koplik**  states  that  the  severity  of  the  constitutional  symptoms 
varies  markedly  in  different  cases:  in  some  instances  they  are  prac- 
tically absent,  but  in  other  cases  may  be  marked  and  accompanied  by 
the  usual  evidences  of  septicemia.  He  has  seen  cases  that  ended 
fatally,  but  this  result  is  probably  due  to  a  general  infection,  rather 
than  to  the  stomatitis.  As  a  general  rule,  this  form  of  infection  is 
milder  in  the  young  than  in  adults.  The  children  often  continue  to 
nurse,  and  alimentation  is  not  interfered  with.  The  mucosa  of  the 
mouth  presents  yellowish  elevations,  which  are  especially  numerous 
over  the  palatine  arches.  The  roof  of  the  mouth  and  the  anterior 
portion  of  the  tongue  are  the  parts  chiefly  affected,  whereas  the  lips 
and  checks  may  be  free.  If  the  yellowish  papules  arc  removed,  they 
will  }>(•  found  to  possess  a  whitish  or  pinkish  liase  that   tends  to  bleed. 

'  Kciplik,  11.:    Disoasrs  of  Infancy  and  Cliiklliood,  New  York  ami  I'liiladclpliia,  tliinl 

Hi.sinski:  Zoitschr.  f.  (!cl),  u.  (!yn.,  Stuttgart,  1891,  vol.  xxii,  p  21(1,  1  pi.;  p.  3.5!l,  1  pi. 

Kra.st:   Inaug.  Di.-.s.,  Honn,  l.Si)4.  '  Dohrn:  tVnI.  f.  Ciyn.,  1891,  No.  22. 

Lfydfn:  Cent.  f.  (lyii.  ii.  Cob.,  l'"el)niary  24,  1H9-1. 
'  .liirKcns:  Berlin,  klin.  Woch.,  Jiiiio  1:5,  1901,  No.  21. 
"  Ro.<<in.ski:  Loc.  cit. 
-  Koplik.  II.:  Di.s(>a.s('.sof  Infancy  and  (■liiliiliood,.\f\v  York  and  I'liiladclpl.ia.  third  cd. 


cd. 


400  GONORRHEA    IN    WOMEN 

111  a  few  daj's  a  purulent  discharge  appears,  which  is  gradually  dis- 
solved by  the  saliva.  Pus  is  especially  noticeable  in  the  region  oc- 
cupied by  the  j'ellowish  ulcers.  The  pus  contains  gonococci.  The 
saliva  may  be  clear.  The  dej^osits  are  never  membranous,  as  in 
diphtheria.     Recovery  usually  takes  place  in  a  few  weeks. 

In  the  adult  gonorrheal  stomatitis  is  a  more  serious  condition.  The 
malady  is  generally  the  result  of  an  infection  contracted  during  buccal 
coitus,  or  it  may  be  a  complication  of  a  well-defined  general  infection. 
The  disease  may  also  result  from  contamination  of  the  mouth  by  infected 
fingers  or  instruments.  Karo^  states  that  gonococci  may  be  present 
in  the  mouth  without  causing  infection.  The  disease  is  characterized 
by  a  sensation  of  heat,  burning,  and  pain  in  the  affected  area.  Expec- 
toration is  copious,  and  consists  of  purulent  saliva,  which  is  often 
blood  tinged  and  of  a  foul  odor.  Eating  causes  intense  pain  and 
sometimes  bleeding.  The  ingestion  of  liquids  also  produces  discom- 
fort. The  patient  complains  of  a  bad  taste,  and  nausea  is  generally 
present.  The  tongue  is  swollen  and  tender,  and  can  be  protruded 
only  a  short  distance.  The  breath  is  foul,  and  the  teeth  may  become 
loose.  On  examination,  the  mucosa,  particularly  that  of  the  soft 
palate,  vulva,  posterior  portion  of  the  tongue,  and  the  cheeks,  is  found 
reddened,  inflamed  and  granular  in  appearance.  The  gums  are 
frequently  retracted  and  spongy.  Numerous  ulcers,  which  vary  in 
size,  may  be  present.  These  bleed  readily  when  touched.  The 
ulcers  are  covered  by  a  whitish  or  yellowish,  sticky,  non-adherent 
membrane.  J^sionek-  has  recorded  the  history  of  a  case  complicated 
by  a  bilateral  gonorrheal  conjunctivitis.  Numerous  grayish-white 
patches  were  present  on  the  mouth  and  tongue.  Soreness  was  marked, 
and  the  sublingual  gland  was  inflamed.  The  gonococci  were  identified 
by  their  morphologic  and  staining  properties.  Vines^  has  reported 
the  history  of  a  case  of  gonorrheal  gingivitis.  The  patient  was  the 
incumbent  of  a  specific  arthritis ;  a  tooth-pick  is  believed  to  have  been 
the  infecting  agent.  Swelling  of  the  jaws  was  marked,  excessive  sali- 
vation was  present,  and  all  the  teeth  were  loose.  The  temperature 
was  101°  F.,  and  the  breath  was  foul.  Recovery  occurred  in  about 
six  weeks.     The  method  of  identification  of  the  gonococci  is  not  stated. 

In  severe  cases  of  stomatitis  the  lips  are  cracked  and  herpes  may 
form.  The  false  membrane  and  the  pus  contain  gonococci.  Moderate 
fever  accompanies  the  acute  stage  of  the  disease. 

Crosby^  has  reported  a  fatal  case  of  septicemia  in  which  gonococci 


'  Karo,  W.;   Internal.  Jour.  iSurg.,  June  29,  1909,  p.  ltj'2. 

2  Jesionek,  A.:  Deut.  Arch.  f.  klin.  Med.,  Leipzig,  vol.  Ixi,  p.  91. 

'  Vines,  S.:  Brit.  Med.  Jour.,  1903,  p.  42.5. 

■•  Crosby,  D.:  Amer.  Jour.  Med.  Soi.,  1905,  New  York,  vol.  cxxi.x,  p.  SSO. 


i 


COMPLICATIONS    AXD    NON-GENITAL    GONORRHEA  401 

were  recovered  from  the  nose,  mouth,  lungs,  trachea,  and  pleura. 
In  this  case  the  stomatitis  was  a  marked  feature.  The  patient  was 
a  man,  thirty-one  years  of  age ;  the  symptoms  of  the  general  infection 
appeared  three  weeks  after  the  acquisition  of  gonorrheal  urethritis. 
The  mouth  and  lips  were  swollen  and  congested,  the  breath  was  foul, 
and  marked  salivation  was  present.  At  autops}-  the  teeth  were 
found  to  be  loose,  and  much  pus  was  present  about  their  roots.  The 
period  of  incubation  in  cases  of  primary  stomatitis  is  not  definitely 
known.  Cutler^  has  recorded  a  case  in  which  the  symptoms  appeared 
in  twenty-four  hours  after  buccal  coitus,  and  were  well  developed 
by  the  fifth  day.  Holder-  has  seen  a  case  in  which  they  appeared  on 
the  fourth  day.  KimbalP  has  recorded  a  case  of  gonorrheal  septi- 
cemia in  an  infant  in  which  the  point  of  entry  seems  to  have  been  by 
way  of  a  stomatitis. 

The  diagnosis  depends  upon  the  demonstration  of  a  specific  micro- 
organism in  the  secretion  or  lesions.  On  account  of  the  not  infrequent 
presence  in  the  mouth  of  organisms  morphologically  and  tinctorially 
similar  to  the  gonococcus,  cultures  are  necessary  to  establish  a  positive 
diagnosis. 

Treatment. — In  infants  the  frequent  washing  of  the  mouth  with 
sterile  water  or  sterile  water  and  glycerin  is  usually  sufficient.  In 
adults  a  more  vigorous  course  of  treatment  is  necessary.  The  mouth 
should  be  cleansed  with  a  solution  of  glycerin  and  bismuth  subnitrate 
solution  and  the  ulcers  touched  with  silver  nitrate.  This  treatment 
should  be  applied  once  or  twice  daily.  A  mouth-wash  containing 
potassium  chlorid,  alum,  or  boric  acid  should  be  employed.  Pro- 
phylactic measures  to  prevent  the  spread  of  the  infection  to  the  eyes 
or  to  other  individuals  should  be  enforced.  Cases  of  gonorrheal 
stomatitis  have  been  reported  by  Leedham-Green,''  Rosinski,''  Cutler,"^ 
Hymen,"  De  Forest,"*  Malherbe,''  and  others. 

NASAL  GONORRHEA 
The  existence  of  nasal  gonorrhea  in  the  adult  is  still  (l()ul)t('d  by 
many  authorities.     Few  recent  instances  of  this  condition  have  been 

'  Cutler:  Quote<I  by  Taylor:  Gcnilo-urinary  and  Vencn-al  Disoa-scs,  1904. 
'  Holder:   Quoted  by  Taylor:  G.-nito-urinary  and  Venereal  Diseases,  1904. 
'  Ivimball,  H.  H.:  Me.l.  Her.,  November  14,  190:5,  p.  401. 
'  Leedharri-Green:  Treatment  of  ( lonorrliea,  London,  1908. 
*  Rosinski:  Zeit.  f.  (iel).  u.  <lyn.,  1S91,  vol.  xxii. 

'Cutler:  Quoted  by  Taylor:  Gi-nito-Urinary  and  Venereal  Disca-ses,  1904. 
'  Hymen,  S.  M.:  New  York  .Mod.  .Jour.,  January  29,  1907. 
»  De  Forest,  H.  P.:  Amer.  Jour.  Ob.st.,  1910,  vol.  Ixi,  p.  1.5;j. 
'  Malherbe,  II.:  Gaz.  mc'-d.  de  Nanles,  1911,  vol.  x\\x,  p.  801. 
20 


402  GONORRHEA    IN    WOMEN 

reported,  and  in  the  majority  of  cases  a  thorough  bacteriologic  exami- 
nation is  lacking.  Diday  and  Bormiere'  endeavored  to  inoculate  the 
nasal  mucous  membrane  of  adults,  but  without  success.  Extension 
of  the  disease  from  an  existing  stomatitis  has  been  asserted  as  a 
cause  by  some  writers,  and  indeed,  this  seems  quite  possible.  De 
Stella-  appears  to  have  definitely  established  the  existence  of  gonor- 
rheal rhinitis  in  the  infant,  and  it  is  not  impossible  that  if  nasal 
discharges  in  the  new-born  were  systematically  examined  with  this 
end  in  view,  gonococci  might  sometimes  be  found.  Owing  to  the 
occasional  presence  of  the  Micrococcus  catarrhalis,  only  cultural 
methods  can  be  accepted  as  positive.  In  Crosby's'  case  of  gonor- 
rheal septicemia  gonococci  were  recovered  from  the  inflamed  nasal 
mucosa,  and  although  no  cultures  were  made,  the  general  clinical 
characteristics  of  the  case  leave  little  doubt  as  to  the  correctness 
of  the  diagnosis.  The  fact,  however,  that  a  gonorrheal  stomatitis 
and  pneumonia  were  present,  and  that  the  patient  was  frequently 
coughing  up  gonococci-laden  sputum,  may  perhaps  account  for  the 
infection,  or  the  latter  may  have  spread  by  direct  continuity  from  the 
mucosa  of  the  mouth.  In  his  report  Crosby  does  not  consider  the 
route  of  the  infection  to  the  nose. 

GONORRHEAL  OPHTHALMIA  NEONATORUM 
Prior  to  the  introduction,  in  1881,  of  the  Crede  prophylactic  treat- 
ment, ophthalpiia  neonatorum  was  an  extremely  frequent  disease. 
Leopold''  states  that  thirty-eight  or  forty  years  ago  every  maternity 
hospital  had  a  room  or  a  suite  set  apart  for  the  treatment  of  sufferers 
from  this  malady.  Interesting  historic  reviews  of  this  disease  may 
be  found  in  the  works  of  Hirschberg^  and  Hausmann.'^  Even  today 
gonorrheal  ophthalmia  neonatorum  is  by  no  means  infrequent. 
Stephenson'  has  collected  data  from  53  provincial  poor-law  lying-in 
departments,  aggregating  17,579  births.  Among  this  number,  128,  or 
0.72  per  cent.,  showed  purulent  ophthalmia.  The  same  authority 
states  that  of  4884  births  in  the  London  hospitals  during  1894-95, 
176,  or  3.6003  per  cent.,  were  attacked  by  this  malady.  Among 
35,815  births  occurring  in  six  British  maternities,  ophthalmia  resulted 
in  79,  or  0.22  per  cent.,  of  cases. 

'  Diday  and  Bormiere:  Quoted  by  Jullien:  Bull,  de  I'Acad.  de  Med.,  Paris,  1907. 

2  De  Stella:  Deut.  med.  Zeit.,  1899,  No.  1. 

'  Crosby,  D.:  Amer.  Jour.  Med.  Sci.,  1905,  New  York,  vol.  cx.\i.x,  p.  880. 

<  Leopold:  Berlin,  klin.  Woch.,  1902,  No.  33. 

'  Hirschberg:  Centralbl.  f.  prak.  Augenheilk.,  1894. 

"  Hausmann:   Die  Bindehautinfektion  der  Neugeborenen,  1882. 

'  Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  10. 


COMPLICATIONS   AND    NON-GENITAL    GONORRHEA  403 

Mayou'  states  that  ophthalmia  neonatorum  cost  the  community 
£350,000  per  year  for  educating  and  looking  after  bUnd  children,  and 
urges  legislative  measures  to  insure  prophylactic  treatment.  Kerr- 
records  that,  in  the  United  States,  the  State  of  Massachusetts  appro- 
priated S40,000  in  1910  for  the  support  of  blind  asylums;  the  State 
of  New  York,  SI  10,000;  whereas  the  biennial  appropriation  of  the 
State  of  Pennsylvania  for  its  blind  asylums  in  1909  amounted  to  $265,- 
000.  When  we  aggregate  private  expenses,  amounts  spent  by  States 
and  cities,  and  also  the  estimate  of  the  potential  earning  power  of 
individuals  thus  disabled,  the  economic  loss  on  account  of  ophthalmia 
neonatorum  will  be  found  to  be  enormous.  Cohen^  states  that  the 
actual  costs  to  the  United  States  are  $1,800,000  yearly  for  the  care 
of  victims  of  ophthalmia  neonatorum  alone. 

The  proportion  of  cases  of  ophthalmia  neonatorum  among  infants 
of  the  poor  who  have  been  born  in  their  own  homes  is  large, 
as  many  of  the  mothers  are  attended  by  ignorant  midwives  and  are 
frequently  the  incumbents  of  neglected  and  uncured  gonorrhea.  The 
frequencj-  of  ophthalmia  neonatorum  naturally  bears  a  direct  ratio 
to  the  prevalence  of  gonorrhea  in  any  given  locality.  As  a  result, 
it  is  less  common  in  country  than  in  urban  populations.  The  most 
frequent  cause  of  ophthalmia  neonatorum  is  the  gonococcus,  this 
organism  being  responsible  for  about  two-thirds  of  the  cases.  Ste- 
phenson'' relates  that  in  the  practice  of  41  observers,  gonococci  were 
found  in  67.14  per  cent,  of  1658  cases  of  ophthalmia  neonatorum. 
deSchweinitz*  states  that  from  60  to  70  per  cent,  of  cases  arc  due  to 
the  gonococcus. 

Other  microorganisms  that  maj'  produce  oi^hthalmia  neonatorum 
are  the  pneumococcus.  Bacillus  coli,  Koch-Weeks  bacillus,  Klebs- 
Loffler  bacillus,  Morax-.Lxenfeld  diplobacillus,  pneumobacillus,  in- 
fluenza and  pseudo-influenza  bacillus,  streptococcus  and  other  connnon 
pyococci,  streptobacillus,  Micrococcus  luteus,  and  Bacillus  pyocy- 
aneus.  The  gonococcus  is  productive  of  the  most  severe  cases  of 
ophthalmia  neonatorum.  Mayou^  has  collected  the  following  sta- 
tistics which  show  the  frequency  with  which  the  gonococcus  is  the 
infecting  agent  in  ophthalmia  neonatorum : 

'  Mayou,  S.  M.:  The  Practitioner,  London,  1908,  vol.  Ixxx,  p.  12.5. 

'Kerr,  ,1.  W.:   Ophthalmia  Xconalorum,  I'uMic  Health  Bull.,  October,  1911,  Xo.  49. 

'  f'ohen,  II.:  111.  Med.  Jour.,  April,  1912,  p.  410. 

"^tcphen.son,  S. :   Ophthalmiu  Neonatorum,  London,  1907,  p.  3.5. 

dcSchwcinitz,  G.  E.:  New  York  .State  .lour.  Med.,  June,  1912,  p.  279. 

Mayou:  The  Practitioner,  London,  1908,  vol.  Ixxx,  p.  2(X). 


404  GONORRHEA    IN    WOMEN 

Percentage  of 
Author  Number  of  Cases  Gonorrheal  Cases 

Kroner 92 68.47 

Haab 16 87.50 

Widmark 25 76.00 

V.  Animon 100 56.00 

Guerola 25 100.00 

Neisser .'. . .       92 68.47 

Andrews 122 100.00 

Hirschberg 32 100.00 

Kopfstein 51 58.82 

Francisco 40 75.00 

Chartres 100 44.00 

Gonin 38 58.00 

Thomin 20 70.00 

Reyling 14 71.42 

Cohn 5.53 52.98 

Groenouw 40 35.00 

Alt 17 52.94 

Stephenson 71 58.67 

Mayou 35 57.50 

Totals 1483 63.50 

Gonorrheal  ophthalmia  in  infants  may  result  from  an  intra-uterine 
infection,  from  contamination  of  the  child's  eyes  during  the  passage 
of  the  fetal  head  through  the  birth-canal,  and  from  postpartum  in- 
fection. These  forms  are  important  because  of  the  difference  in  the 
time  at  which  the  disease  becomes  manifest.  Considerable  discussion 
has  arisen  as  to  the  etiology  of  the  intragenital  development  of  oph- 
thalmia neonatorum,  and  various  theories  have  been  advanced. 
As  early  as  1840  Crompton'  reported  the  histoiy  of  a  case  in  which 
ophthalmia  was  advanced  at  birth.  Rivaud-Landrau,-  Wordsworth,^ 
and  Hausmann^  are  among  the  early  observers  of  this  condition. 
Golesceano'  states  that  this  variety  of  ophthalmia  was  present  in 
9.67  per  cent,  of  a  series  of  186  cases.  Of  25  cases,  Wiirdemann''  found 
that  symptoms  of  ophthalmia  were  present  in  20  per  cent,  of  the  in- 
fants at  birth.  CoUins''  observed  this  condition  once  in  32  cases. 
Collingsworth,*  Veit,'  and  Jardine^"  refer  to  cases  in  which  ophthalmia 
has  been  present  in  infants  delivered  by  abdominal  cesarean  section. 
Barnes,"  Taylor,^-  and  Nieden"  have  observed  cases  of  antepartum 

'  Crompton,  S.:  London  Medical  Gazette,  new  series,  1840-41,  vol.  i,  p.  432. 

-  Rivaud-Landrau:  Annales  d'oculistique,  1857,  vol.  i,  p.  66. 

'  Wordsworth,  J.  C:  Brit.  Med.  Jour.,  May  2,  1863. 

''  Hausmann:   Die  Bindehautinfektion  der  Neugeborenen,  1882. 

^Golesceano:  Bull,  et  mom.  de  la  Sec.  frangaise  d'ophtalmologie,  1904,  p.  347. 

*  Wurdemann:  Amer.  Jour.  Ophthalmology,  May,  1893,  p.  151. 

'  Collins:  The  Practitioner,  1902,  p.  428. 

'  Collingsworth:  Trans.  London  Obst.  Soc,  July,  1903,  vol.  xlv,  p.  356. 

5  Veit:  Quoted  by  Barnes,  F.:  Brit.  Med.  Jour.,  November  5,  1881,  p.  740. 

">  Jardine,  R.:  Trans.  Edin.  Obst.  Soc,  1904,  vol.  xxix,  p.  151. 

"  Barnes,  F.:  Brit.  Med.  Jour.,  November  5,  1881. 

1-  Taylor,  H.  S.:  Brit.  Med.  Jour.,  March  18,  1871. 

"  Nieden:  Klin.  Monats.  f.  Augenheilk.,  October,  1891,  p.  353. 


COMPLICATIOXS    AND    XON-GEXITAL    GONORRHEA  405 

ophthalmia  in  infants  born  with  a  caul.  In  Taylor's  case  the  child 
was  delivered  with  the  bag  of  waters  unruptured.  As  a  result  of 
antepartum  infection,  either  advanced  or  newlj^  acquired  ophthalmia 
may  be  observed  at  birth,  or  the  malady  may  develop  shortly  after 
delivery.  Early  rupture  of  the  membranes  doubtless  accounts  for  a 
certain  proportion  of  these  cases.  Systemic  infection  may  also  ex- 
plain a  limited  number.  Stephenson  favors  the  theory  of  local  intra- 
uterine infection  in  the  majority  of  cases,  basing  his  opinion  upon  his 
clinical  experience  and  upon  the  experimental  work  of  Hellendall,^ 
who  has  shown  that  bacteria  may  penetrate  the  intact  membranes. 
Little  more  than  one-third  of  the  cases  of  intra-uterine  infection  can 
be  accounted  for  by  premature  rupture  of  the  membranes.  In  the 
remaining  cases  slight  trauma  or  injiu-y  to  the  membranes,  or  even 
actual  penetration  of  the  latter  by  the  microorganism,  seems  to  be 
the  most  probable  explanation  of  this  variety  of  infection.  According 
to  Dorland,-  ''congenital  ophthalmia"  is  more  common  than  is  gen- 
erally supposed,  he  having  found  about  100  cases  on  record. 

By  far  the  greatest  number  of  eyes  are  infected  during  or  immedi- 
ately following  labor,  the  symptorns  usually  appearing  before  the 
fifth  day.  If  it  were  not  for  the  fact  that  at  birth  the  eyes  are  usually 
tightly  closed  and  more  or  less  sealed  by  the  fattj^  Meibomian  secretion, 
infection  would  doubtless  be  much  more  frequent.  Infections  oc- 
curring some  time  after  birth  or,  as  they  are  termed,  secondary  in- 
fections, are  frecjuent,  constituting  probably  about  one-fourth  of  all 
the  cases.  Owing  to  the  variability  of  the  period  of  incubation  of 
the  gonococcus,  it  is  impossible,  in  many  instances,  positively  to 
determine  at  what  time  and  in  what  manner  the  contamination  took 
place.  Wintersteiner"'  refers  to  122  cases  of  ophthalmia  in  which 
32.78  per  cent,  were  attacked  after  the  fifth  day.  Among  a  series  of 
739  cases  reviewed  by  Stephenson,'  48.65  to  80.64  per  cent,  developed 
symptoms  within  four  days.  Secondary  infection  may  be  conveyed 
by  the  hand  or  by  contamination  of  variouf?  articles  brought  in  con- 
tact with  the  eyes,  such  as  sponges,  water,  towels,  etc.  Knies^  men- 
tions an  epidemic  caused  by  a  midwife,  who  was  herself  (lie  iiununbent 
of  an  uncured  genital  gonorrhea. 

Symptoms. — These  usually  apju-ar  witliiii  the  first  five  days,  one 

'  Hclli'iKlall.  M.:   Hcilriin"'  /■■  <i'-l).  u.  (!yn.,  lii().-)   1!  Oli,  vol.  x.  pp.  1  ami  :52(). 

Ddil.iiKl,  W.  A.  X.:   .lour.  Amcr.  Med.  A.-^soc,  OrtoIxT  14,  1911,  p.  12,S.->. 
■  Wiiilcr.stcincr:   Wicn.  kliii.  Wodi.,  .Soplcinhcr  1.5,  KKM,  p.  1>HS. 
*  Stophonson,  S.:  Ophlhalniia  Xconalonim,  Loiidoii.  1007,  p.  1  Hi. 
'  Knics:    Dio  gonorrlioi.sehcn   IJiiKlcliautcrkraiikuiiKcn  u.  (icrcii   Bcliandliiiin.   Ilallc, 
ISOr,,  p.  <). 


406  GONORRHEA    IN    WOMEN 

or  both  eyes  being  affected.  According  to  Billard/  the  earliest  sign 
is  a  narrow,  transverse,  congested  line  that  appears  in  the  center  of 
the  upper  lid.  Thi^  is  rapidly  followed  by  more  marked  evidence  of 
inflammation.  The  eyelids,  especially  the  upper  one,  become  hot, 
reddened,  tender,  and  swollen.  A  yellowish  or  greenish  secretion 
soon  appears,  and  the  swelling  of  the  affected  parts  becomes  more 
marked.  On  account  of  the  edema  it  is  sometimes  impossible  to 
separate  the  lids  without  the  aid  of  a  lid-elevator.  In  severe  cases 
the  upper  lid  may  hang  over  the  lower.  Attempts  at  examination 
cause  acute  pain.  The  secretion  is  copious,  and  the  conjunctiva  is 
reddened,  thickened,  and  congested.  A  pseudomembrane  not  un- 
commonly is  present.  The  ocular  conjunctiva  is  not,  as  a  rule,  severely 
affected,  and,  unlike  gonorrheal  conjunctivitis  in  the  adult,  may  show 
but  little  chemosis,  probably  due  to  the  fact  that  in  new-born  infants 
the  eyes  are  always  closed.  Ulcerations,  varying  in  size,  may  be 
found  upon  the  tarsal  conjunctiva.  As  the  disease  progresses  the 
swelling  tends  to  subside,  leaving  the  lids  wrinkled.  At  this  stage 
they  can  readily  be  everted.  In  severe  or  untreated  cases  the  cornea 
may  become  infiltrated,  present  an  opaque  appearance,  and  be  the 
seat  of  one  or  more  ulcers.  The  corneal  tissue  may  regenerate  or 
perforation  may  occur,  with  resulting  pyramidal  cataract,  adherent 
leukoma,  and  corneal  staphyloma;  or  severe  intra-ocular  inflammation 
may  occur,  resulting  in  panophthalmitis  or  atrophy  of  the  globe. 
In  eyes  with  central  corneal  opacities  the  result  of  previous  ulceration, 
amblyopia,  nystagmus,  and  squint  may  subsequently  develop.  Blind- 
ness is  not  infrequently  the  termination  in  neglected  or  untreated  cases. 
Stephenson^  states  that  tenderness  and  tumefaction  of  the  preauricular 
gland,  which  is  in  direct  communication  with  the  conjunctiva,  is  a 
frequent  complication  of  gonorrheal  ophthalmia.  Moderate  fever 
and  its  accompanying  phenomena  are  usually  present.  During  the 
height  of  the  attack  infants  often  suffer  from  diarrhea  and  refuse  the 
nipple.  Wolfrum^  has  recently  described  cases  of  ophthalmia  neo- 
natorum that  closely  resembled  trachoma. 

Hoeck*  and  Berger''  have  referred  to  cases  complicated  by  ab- 
scesses about  the  lids,  and  Suker"  records  a  case  in  which  infection 
of  the  anterior  ethmoid  cells  occurred.     Arthritis  as  a  complication 

'  Billard:  Trait(5  des  Mai.  des  Enfants  Nouveau-nds,  third  ed.,  p.  274. 

^  Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  141. 

'  Wolfrum,  M.  C:  Munch,  med.  Woch.,  July,  1911,  No.  28,  p.  1.503. 

'  Hoeck:  Jahresber.  der  Ophth.,  1894,  p.  531. 

'  Berger:  Arch,  d'ophtal.,  vol.  i,  No.  14. 

«  Suker,  G.  F. :  Annals  Ophthal.,  April,  1905. 


I 


4 
i 


COMPLICATIONS    AND    NON-GENITAL    GONORRHEA  407 

has  been  observed  bj^  Alt  land'  and  others.  Paulsen,-  Haushalter,' 
Deutschmann/  Stevens,^  Chartres/  and  Stephenson'  have  mentioned 
cases  accompanied  by  septicemia.  Widmark^  relates  the  history  of 
a  fatal  case  of  ulcerative  endocarditis,  while  Politzer^  mentions  a  case 
followed  by  meningitis.  Mayou'"  states  that  among  other  complica- 
tions may  be  found  infection  of  the  lacrimal  gland  and  rhinitis. 

According  to  Crede,"  the  predisposing  causes  of  gonorrheal  oph- 
thalmia neonatorum  are  premature  rupture  of  the  membranes  and  a 
protracted  second  stage  of  labor.  Mayou'-  believes  that  in  the  infant 
the  marked  susceptibility  of  the  conjunctiva  to  infection  is  due  to 
the  deficiency  of  the  epithelium  and  the  underdevelopment  of  the 
lymphoid  tissue.  Gueirel,'-'  Cramer,'^  Stephenson,'^  and  ZweifeP*  state 
that  desquamation  of  the  oculopalpebral  surface  and  certain  other 
changes  that  are  often  present  in  premature  children  are  predisposing 
factors  to  this  condition.  Doubtless  the  absence  of  lacrimal  secre- 
tion, which  normally  occurs  in  the  newborn,  is  also  a  contributing 
cause.  Ophthalmia  neonatorum  is  more  frequent  in  cephalic  than 
in  other  forms  of  presentation.  Face  presentations  especially  favor 
infection. 

Ophthalmia,  while  not  generally  a  fatal  disease,  frequently  leaves 
the  patient  hopelessly  blind  or"  with  impaired  vision.  Burdett"  has 
estimated  that  of  the  50,5(58  blind  persons  in  the  United  States,  as 
shown  by  the  census  of  1890,  no  less  than  39  per  cent,  owed  their 
condition  to  ophthalmia  neonatorum. 

A  committee  of  the  British  Medical  Association  found  that  more 
than  one-third  of  the  pupils  of  the  blind  schools  of  Great  Britain  owed 
their  affliction  to  this  disease."*  In  the  United  States  and  Canada, 
in  1907,  out  of  224  admissions  to  10  schools  for  the  blind,  59,  or  24.38 

'  Altland:  Klin.  Monatsbl.  f.  Augonhcilk.,  April,  1902. 

'  Paulsen:   Miinch.  med.  Woch.,  August  28,  1900. 

"  Haushalter:  La  Semaine  Mt'd.,  LS9.5,  vol.  i,  No.  14,  p.  380. 

*  Deutschmann:  V.  Gracfe's  Arch.  f.  Ophthalmologio,  1890,  vol.  xxxvi.  No.  1,  p.  109. 

'Stevens,  E.  \V.:   Ophthal.  Hec,  November,  190r>. 

'•  C'liartre.s,  E.:  Tliese  de  Hordeau.\,  1S9(),  p.  27. 

'  .Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  1  i'.i. 

'  W'idm.irk,  J.:  Rev.  gen.  d'ophtalmologie,  Paris,  1888,  vol.  vii,  p.  l-l."i. 

'  Politzcr:   Jahr.  f.  Kinderheilk.,  1870,  p.  335. 

'"  Mayou,  S.:  The  Practitioner,  1908,  pp.  12.5,  200,  354. 

"  Crede:   Arch.  f.  (!yn.,  18.S3,  vol,  xxi,  p.  179. 

'-  Mayou,  S.:   The  Practitioner,  1908,  pp.  125,  200,  354. 

"(iueirel:   Legons  de  Clinique  Obstetricale,  Paris,  1902,  p.  198. 

"Cramer:   Arch.  f.  (!yn.,  1H99,  vol.  lix.  No.  1. 

"Stephenson,  .S.:   Ophthalmia  Neonatorum,  London,  1902,  p.  130. 

"Zweifel:   Cent.  f.  (lyn.,  1900,  p.  1374. 

"  Hurdett,  S.  M.:   Century,  1892.  '•'  Mrit.  Med.  .lour..  May  S,  1909. 


408  GONORRHEA    IN    WOMEN 

per  cent.,  were  sightless  as  a  result  of  ophthalmia  neonatorum.'  Of 
351  admissions  to  certain  schools  in  the  United  States  and  Canada 
in  1910,  84,  or  23.9  per  cent.,  were  bUnd  from  this  cause.  Greene  has 
studied  ophthalmia  neonatorum  in  10  manufacturing  cities  of  Massa- 
chusetts, and  has  found  that  the  minimum  morbidity  for  this  disease 
was  6.4  per  1000  births.  This  investigator  also  compiled  statistics 
obtained  from  173  physicians  practising  in  9  different  cities.  In  this 
series  the  morbidity  rate  was  10.8  per  1000  births.  RocklifTe^  found 
that  in  the  Hull  Blind  Institution,  of  590  cases  of  blindness,  91  were  the 
result  of  ophthalmia  neonatorum. 

From  data  collected  by  Stephenson^  it  is  shown  that  of  5995  cases 
of  ophthalmia  neonatorum  treated  in  16  ophthalmologic  hospitals, 
22.85  per  cent,  lost  their  sight  or  suffered  an  impairment  of  vision. 

Diagnosis. — The  diagnosis  of  gonorrheal  ophthalmia  neonatorum 
depends  upon  the  bacteriologic  demonstration  of  the  specific  micro- 
organism. If  any  delay  is  caused  by  obtaining  a  microscopic  examina- 
tion of  the  secretion,  or  doubt  exists  as  to  the  presence  of  gonococci,  the 
case  had  better  be  treated  as  one  of  gonorrhea  until  a  thorough  labora- 
tory investigation  can  be  carried  out.  Various  forms  of  systemic  gonor- 
rhea may  result  from  ophthalmia  neonatorum.  In  1899  Lucas*  was 
able  to  collect  from  the  literature  the  reports  of  23  cases  of  joint  lesions 
due  to  this  type  of  infection;  18  of  these  cases  followed  ophthalmia 
neonatorum,  whereas  in  the  remaining  5  the  infection  was  ac- 
quired later  in  life.  The  following  authors  are  quoted  by  Lucas=  as 
having  recorded 'authentic  cases  of  this  condition:  Lucas,^  Fenwick,^ 
Zatvornitski,^  Debierre,' Widmark,'"  Darier''  (2  cases),  Deutschmann'- 
(2    cases),   Lindermann,"    Morax,'*   Escherich,'*   Hoeck'"    (2    cases), 

'  Jour.  Amcr.  Med.  Assoc,  May  23,  1909,  p.  1745. 

-  Rockliffe,  W.  C:   Brit.  Med.  Jour.,  March  9,  1912. 

'  Stephen.son,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  14. 

'Lucas,  R.  C:  Med.-Chirurg.  Trans.,  pubhshed  by  the  Roy.  I\Ied.  and  Chir.  Soc, 
London,  1899,  vol.  Ixxxii;  second  .series,  vol.  Ixiv,  p.  137. 

*  Lucas:  Loc.  cii. 

«  Lucas,  R.  C:  Brit.  Med.  Jour.,  July  11,  1885;  also  Brit.  !Mcd.  Jour.,  October  10,  1885. 

'  Fenwick,  R.  G.:   Brit.  Med.  Jour.,  October  31,  1885. 

»  Zatvornitski :   Ophthal.,  1885. 

'  Debierre,  L.:   Rev.  gen.  d'ophtal.,  1885,  p.  209. 

"  Widmark,  J.:   Jahrb.  f.  Kinderheilk.,  1886,  vol.  xxix,  p.  1.52. 

"  Darier:  Arch,  d'ophtal.,  1889,  p.  175. 

'■- Deutschmann :   Arch.  i.  Ophthal.  1890,  p.  107. 

"  Lindermann;   Beitrage  z.  Augenheilk.,  June,  1892,  No.  5,  p.  30. 

"  Morax:   Progres  MMicale,  October  22,  1892. 

'=^Escherich:  Jahrb.  f.  Kinderheilk.,   October,  1893. 

"  Hoeck:  Wien  klin.  Woch.,  October  12,  1893,  p.  736. 


COMPLICATIONS   AND    NON-GENITAL    GONORRHEA  409 

Sobotka,'   Moncorvo,-    Haushalter,-'*    Griffon,^    Tyrrell,'   Ashby    and 
Wright/  and  Berenstein." 

Treatment. — Prophylactic  Treatment. — During  and  preceding  labor 
the  mother  should  receive  the  treatment  previously  outlined  under 
Treatment  of  Gonorrheics  During  Labor.  The  efficiency  of  the  Crede 
method  is  amply  proved  by  the  statistics  of  Leopold,^  Haab,^  the 
Rotunda  Hospital  Reports/"  and  by  those  from  practically  all  large 
maternities.  It  has  been  asserted  that  the  instillation  into  the  eye 
of  a  1  or  2  per  cent,  solution  of  silver  nitrate  may  produce  a  con- 
junctival catarrh,  conjunctival  hemorrhage,  or  even  corneal  opacities. 
If  the  method  is  properly  carried  out,  and  the  weaker  of  these  solu- 
tions is  employed,  these  complications,  if  they  occur  at  all,  constitute 
so  extremely  small  a  proportion  that  they  may  practically  be  ignored. 
In  this  connection  Hellendall's'^  recent  report  is  of  interest.  This 
observer  has  collected  data  from  28  clinics,  with  a  total  of  over  50,000 
cases.  He  concludes  that  when  the  so-called  silver  catarrh  occurs, 
it  is  the  result  of  impure  preparations  being  employed,  which  liberate 
free  sulphuric  acid.  According  to  Hellendall,  a  1  per  cent,  silver 
nitrate  solution  never  produces  a  reaction.  The  original  Cred^'^ 
method  prescribed  the  u.se  of  a  2  per  cent,  solution  of  silver  nitrate. 
This,  however,  was  found  to  be  too  strong,  clinical  experience  having 
demonstrated  that  equally  good  results  may  be  obtained  with  a  weaker 
solution.  Runge,''  Hofmeier,'''  von  Hecker,''  Dauber,'"  Leopold,'^ 
and  many  others  recommend  a  1  per  cent,  solution.  Very  satisfactory 
results  have  also  been  obtained  by  the  employment  of  a  1 :  4000  cor- 
rosive sublimate  solution,  or  one  of  the  newer  silver  preparations,  such 
as  argyrol,  protargol,  or  silver  acetate  (1  or  1.25  per  cent.)  instead  of  the 
silver  nitrate.     Zweifel'*  recommends  a  weak  solution  of  silver  acetate. 


'.Sobotka:    I'loj;.  iiicil.  Wodi.,  1893,  p.  .582. 

■  .Moncorvo:   La  Mod.  Infantile,  July  1"),  1894. 

'  Hau.-ihalter:   Kov.  Mon.s.  dos  Mai.  <li'  rcnfance,  October,  189.'). 

'  Griffon:    Pre.s.<<c  .MC-d.,  1896,  No.  1.5.  '  Tyrrell:  Med.  News,  March  7,  18911,  p.  271. 

'•  .\.shby  and  Wright:   Di.se!i,se.s  of  Children,  189(5. 

■  Heren.stein:   Cent.  f.  prak.  .Vugenhcilk.,  March,  1897,  p.  84. 
•  Leopold:   Munch,  meil.  Woch.,  May  1,  190ti. 

'■'  Haal):   ('ornwpondenzbl.  f.  Schw.  Arztc,  lS8(i,  vol.  xv,  p.  7. 
'"  Rotunda  Hospital,  clinical  report.s  of,  190.5  and  1901), 

"  Hell.Tidall:    Monats.  f.  (iob.  u.  Cyn.,  1911,  vol.  xxxiii,    No.  2,  p.  42;   also  Zenlralbl. 
Ciyniik.,  I>iipziK,  1911,  vol.  xxxv,  p.  1453. 
'-'Crede:   .\rch.  f.  Cyn.,  1881,  vol.  xviii,  p.  'iiSl . 
"  UunKc,  K.:   Heriin.  klin.  Woch.,  May  19,  19(r2,  p.  20. 
"  Ilofnieier:    Kef.  Medical  News,  .September  23,  1905. 
''  von  Meeker:   .\nh.  f.  Cyn.,  vol.  xx,  No.  3,  p.  378. 
'»  Dauber:   .Vlinich.  meil.  Woch.,  February  Hi.  1904,  p.  297. 
'"  Leopold:   .Miinch.  med,  Woch.,  May  1,  19011. 
"  Zweifel:   Zentralbl.  f.  Cyn.,  July  (>,  1912. 


410  GONORRHEA    IN   WOMEN 

On  account  of  the  non-irritating  properties  of  argyrol  and  protargol, 
these  preparations  may  with  advantage  be  substituted  for  silver  nitrate 
in  cases  in  which  it  is  necessary  to  have  the  application  made  by  an 
unskilled  attendant.  Either  protargol  or  argyrol  must  be  applied 
frequently  if  good  results  are  to  be  obtained.  Of  the  two,  argyrol  is 
the  more  efficient  remedy,  and,  while  less  irritating,  its  germicidal 
action  is  not  so  marked.  It  should  be  freshly  prepared  with  cold 
water  and  stored  in  a  dark  place.  For  routine  work  nothing  has  as 
yet  proved  equal,  in  the  writer's  opinion,  to  a  silver  nitrate  solution 
of  1  or  1.25  per  cent,  strength.  Its  gonococcidal  properties  are  far 
superior  to  those  of  any  of  the  other  silver  preparations.  For  statistics 
pertaining  to  the  action  of  various  drugs  employed  for  prophylactic 
purposes  see  Chapter  XX. 

Prophylactic  Technic. — As  soon  as  the  head  is  born  the  eyes  should 
be  wiped  with  absorbent  cotton  moistened  with  boric  acid  solution 
(10  grains  to  the  ounce) ;  following  this,  as  quickly  as  may  be  con- 
venient, a  thorough  irrigation  of  the  eyes  with  a  similar  solution  should 
be  resorted  to,  after  which  2  drops  of  a  1  per  cent,  solution  of  silver 
nitrate  should  be  instilled  into  each  eye.  This  need  not  be  neutralized. 
Care  should  be  observed  to  see  that  the  solution  is  well  distributed. 
The  arms  and  hands  should  be  dried  as  soon  as  possible,  and  the  baby 
so  placed  that  it  cannot  touch  its  eyes.  In  cases  in  which  the  mothers 
are  known  to  be  gonorrheics,  the  plan  suggested  bj'  Abbott,^  which 
consists  in  placing  a  small  occlusive  bandage  over  the  eyes  as  soon  as 
the  face  has  beeii  cleansed  with  a  damp  antiseptic  cloth,  may  also  be 
employed.  Care  must  always  be  observed  to  avoid  possible  post- 
partum infection.  For  this  reason  the  infant's  face  should  be  washed 
separately  from  the  remainder  of  its  body. 

To  prevent  late  infection,  all  women  the  incumbents  of  a  gonorrhea 
should  be  warned  of  the  infectious  nature  of  the  discharge,  and  chil- 
dren should  be  absolutely  forbidden  to  sleep  in  the  same  bed  with 
infected  parents. 

Any  measui'es  that  will  lessen  the  l)re^•alence  of  gonorrhea  will 
also  diminish  the  frequency  of  gonorrheal  ophthalmia.  Such  means 
have  been  discussed  in  a  previous  chapter.  Notification  of  ophthalmia 
neonatorum  seems  to  be  especially  effective  in  this  variety  of  gonor- 
rhea. In  Paris,  London,  and  certain  parts  of  the  United  States  noti- 
fication is  imperative.  deSchweinitz-  states  that  in  Boston,  where 
notification  is  compulsory,  not  a  single  known  instance  of  the  disease 
having  resulted  in  blindness  has  occurred  in  any  of  the  reported  cases. 


'  Abbott,  G.  E.:  Med.  Rec,  September  21,  1889,  p.  .317. 

■  deSchweinitz,  G.  E. :  New  York  State  Jour.  Med.,  June,  1912,  p.  279. 


1 


COMPLICATIONS    AXD    XON-GENITAL    GONORRHEA  411 

The  Social  SerA-ice  Department  of  the  University  of  Pennsylvania 
Hospital  has,  by  prompt  attendance  in  such  cases,  saved  the  sight 
of  many  children.  Notification  not  onh'  secures  prompt  and  efficient 
treatment,  but  also  insures  the  enforcement  of  proper  measures  to 
prevent  the  spread  of  the  disease.  In  addition,  valuable  data  can 
thus  be  obtained.  All  midwives  should  be  taught  how  to  apply  proper 
prophylactic  measures  against  this  disease. 

Curative  Treatment. — In  the  treatment  of  ophthalmia  neonatorum, 
as  in  other  forms  of  gonorrheal  infection,  the  indications  are  to  keep 
the  affected  area  clean  and  to  destroy  the  gonococci.  As  the  dis- 
charge in  this  form  of  infection  is  extremely  copious  and  is  thrown 
off  in  amazing  quantities,  frequent  cleansing  of  the  eyes  is  necessary. 
Boric  acid,  sterile  water,  and  normal  salt  solution  are  all  excellent 
for  this  purpose.  Stephenson^  prefers  mercury  oxycyanid  (1:4000) 
or  potassium  permanganate  (1:2000).  Whatever  solution  is  selected, 
it  should  be  warmed  to  body  temperature  before  being  used.  As 
has  been  previously  stated,  the  indication  is  to  remove  the  discharge 
as  soon  as  it  is  formed.  In  order  to  accomplish  this,  it  is  usually 
necessary,  at  least  during  the  height  of  the  malady,  to  make  the  appli- 
cations hourly  or  even  more  frequently.  Among  private  patients 
this  requires  the  services  of  a  day  and  a  night  nurse.  Kalt^  recom- 
mends frequent  cleansing  of  the  eyes  by  means  of  an  irrigator, 
the  rubber  tube  being  attached  to  a  small,  expanded,  trumpet-shaped 
nozle.  The  latter  is  introduced  between  the  lids  and  the  discharge 
washed  away.  He  employs  1  or  2  quarts  of  solution,  warmed  to  body 
temperature,  three  or  four  times  daily,  and  uses  no  other  treatment. 
He  reports  good  results.  Needless  to  say,  this  treatment  should  not 
be  intrusted  to  unskilled  hands,  and  care  should  be  taken  not  to  cause 
an  abrasion  of  the  cornea.  During  the  height  of  the  disease  ice- 
compresses  are  of  benefit  in  reducing  the  swelling  and  pain.  Theo- 
retically, they  are  also  of  advantage  in  reducing  the  temperature  of 
the  conjunctiva  to  a  point  below  which  the  gonococcus  thrives.  In 
all  cases  ice-compresses  should  be  employed  intermittent}}' for  at  least 
the  first  twenty-four  hours  and  in  most  cases  longer.  deSchw(>initz^ 
and  Standish  are  strong  advocates  of  the  routine  use  of  ice. 

To  destroy  the  gonococci  the  eyelids  should  be  everted  and  the  eye 
thoroughly  waslicd  with  a  cleansing  solution,  such  as  boric  acid.  The 
irrigation  should  be  continued  until  all  pus  and  fibrin  have  been  re- 
moved.    The  lids  and  conjunctiva  should  then  be  lightly  swabbed 

'Stephenson,  S.:  Oplilluilinia  Nconaloniiii,  l.oiulon,  1007,  p.  'JIM. 
«  Kalt:  .\rch.  d'Ophtiiinioloiru-,  1.S<I4,  vol.  i,  No.  11,  p.  7.S(). 
'  deScliweinit/.,  G.  E.;  Thcrap.  Gaz.,  January  !•">,  l'Jl)7. 


412  GONORRHEA    IN    WOMEN 

with  a  1  per  cent,  solution  of  silver  nitrate  until  a  whitish  film  of 
coagulated  albumin  forms.  The  more  severe  the  case,  and  the  more 
copious  the  secretion,  the  stronger  should  be  the  solution  of  silver 
employed,  but  a  2  per  cent,  solution  will  invariably  be  found  to  be  of 
sufficient  strength.  Especial  care  should  be  observed  not  to  touch 
the  cornea.  The  eye  is  then  irrigated  with  physiologic  salt  so- 
lution until  the  white  film  has  entu'ely  been  washed  away.  The 
lids  are  then  turned  back  to  their  normal  position  and  the  sac  once 
more  irrigated.  Ice-compresses  may  then  be  applied  for  five  or  ten 
minutes.  This  treatment  should  be  applied  daily,  and  should  be 
administered  by  the  physician  or  by  a  specially  instructed  nurse. 
The  author  favors  the  use  of  silver  nitrate  over  all  other  drugs  for 
the  treatment  of  gonorrheal  ophthalmia  neonatorum.  Argyrol,  pro- 
targol,  and  other  silver  preparations  have  many  advocates.  Argyrol 
is  the  most  popular  of  these  preparations.  Stephenson^  invariably 
commences  the  treatment  with  a  25  per  cent,  solution  of  argyrol 
applied  to  the  conjunctiva,  repeating  the  application,  according  to 
the  severity  of  the  symptoms,  one,  two,  three,  or  four  times  in  the 
twenty-four  hours.  If  decided  improvement  is  not  noted  after  three 
or  four  treatments,  silver  nitrate  is  employed.  A  corneal  ulcer  that 
does  not  heal  under  argyrol  is  another  indication  for  the  use  of  silver 
nitrate.  One  of  the  great  advantages  of  argyrol  is  that  the  applica- 
tion may  be  safely  intrusted  to  the  infant's  friends.  When  argyrol 
is  to  be  employed,  the  eyes  should  be  freely  irrigated  with  the  solution. 
According  to  deSchweinitz,^  the  immersion  treatment  of  H.  D.  Bruns, 
which  consists  in  building  a  dam  about  the  eyes  and  then  flooding 
them  with  solution,  is  one  of  the  best  methods  of  applying  this  drug. 
Argyrol  possesses  distinct  cleansing  properties,  prevents  the  lids  from 
becoming  adherent,  and  seems  to  penetrate  deeply  between  the  folds 
of  the  edematous  mucosa.  Its  employment  does  not  prevent  the  use 
of  silver  nitrate,  and,  indeed,  many  authorities  recommend  that  both 
drugs  be  used,  the  argyrol  being  applied  four  or  more  times  in  the 
twenty-four  hours,  and  the  silver,  once  or  twice.  This  treatment,  as  a 
rule,  gives  excellent  results.  It  must,  however,  be  remembered  that  ar- 
gyrol has  no  control  over  the  specific  nature  of  the  disease.  The  appli- 
cation of  silver  should  be  continued  until  the  discharge  becomes  thin 
and  scanty  and  the  gonococci  have  disappeared.  It  should  then  be 
applied  two  or  three  times  a  week  until  an  entire  cure  has  been  effected, 
as  proved  by  the  absence  of  clinical  symptoms  and  the  results  of 
bacteriologic  examinations. 

'Stephenson,  S.:  Ophthalmia  Neonatorani,  Li)iulun,  I'JOT. 
-  deSchweinitz,  G.  E.:   Loc.  cit.,  p.  4. 


COMPLICATION'S    AND    NOX-GEXITAL    GONORRHEA  413 

In  this  connection  it  is  interesting  to  note  that  Ciroenouw^  has 
found  gonococci  in  the  eyes  twenty-five  days  after  the  discharge  had 
ceased.  This  emphasizes  the  importance  of  making  thorough  bac- 
teriologic  examinations  in  every  case  before  concluding  that  cure  is 
complete. 

If  the  disease  is  unilateral,  the  other  ej^e  should,  of  course,  be  pro- 
tected from  possible  contamination.  If  corneal  complications  have 
not  ari.sen,  the  average  duration  of  gonorrheal  ophthalmia  neonatorum 
is  about  four  to  six  weeks.  The  attendants  on  a  case  of  gonorrheal 
ophthalmia  should  all  be  warned  of  the  infectious  nature  of  the  dis- 
charge, and  prophylactic  measures,  to  safeguard  them  and  others, 
should  be  instituted.  Protective  glasses,  or  ordinary  motor  goggles, 
are  excellent  shields  against  infection. 

deSchweinitz- and  Holloway'  have  both  directed  attention  to  the 
frequency  of  gonorrheal  conjunctivitis,  or,  as  it  is  termed,  ophthalmo- 
blennorrhea or  gonoblennorrhea  of  young  girls.  This  condition  is 
frequentl}^  associated  with  epidemics  of  vulvovaginitis.  It  is  produced 
either  by  auto-infection  or  by  contamination  from  towels,  clothing,  or 
other  articles.  The  symptoms  are  similar  to  those  seen  in  ophthalmia 
neonatorum,  and  the  treatment  is  the  same. 

Gonorrheal  Conjunctivitis  in  the  Adult. — This  is  gcnerallj'  the  re- 
sult of  auto-infection,  but  may  be  systemic  or  caused  by  contamina- 
tion from  virulent,  gonococci-bearing  material  from  another  individual. 
The  disease  is  relatively  less  fre(}uent  among  adults  than  among  in- 
fants. Indeed,  when  one  considers  the  number  of  cases  of  acute 
urethritis  seen  in  the  average  genito-urinary  dispensary,  and  their 
generally  filthy  personal  hygiene  and  low  mentality,  it  would  almost 
seem  as  if  the  adult  conjunctiva  must  possess,  to  some  extent  at  least, 
a  partial  immunity  to  this  organism. 

Symptoms.  The  symptoms  of  gonorrheal  conjunctivitis  in  the  adult 
usually  appear  in  from  twelve  to  forty-eight  hours.  The  height  of  the 
disease  is  reached  in  about  ten  days,  after  which  a  gradual  subsidence 
begins,  la.'^ting  one  or  two  months.  In  rare  cases  chronic  conjunctivitis 
may  persist  longer,  (lonorrheal  conjunctivitis  in  adults  is  more  serious, 
and  the  prognosis  is  distinctly  less  favoral)le  than  is  a  similar  condition 
in  infants.  The  symptoms,  although  generally  similar,  differ  in  some 
essentials.  The  chemosis  of  the  bulliar  conjunctiva  is.  as  a  rule,  much 
more  severe,  corneal  iiivdlvcnicnt   is  nmrc  frcciucnt ,  and  ulcers  ar(>  of 

'  Cirooiiouw:  Grsu^fc's  .Vrch.  f.  Ophth.,  Li-ipziu,  I'.IOl,  p.  1  (this  jiilicic  cinilains  a  re- 
view of  tlio  foreign  literature  to  1901). 

2  (leSehweiiiitz,  ( !.  IC. :  Tlierap.  (iuz.,  Juiuiary  1."),  li)l)7. 

»  llolloway,  T.  H.:  .lour.  Aiiier.  Med.  Assoc,  April  13,  1(107,  p.  l-'.-.l. 


414  GONORRHEA    IN   WOMEN 

even  graver  significance.  There  is  a  tendency  for  these  ulcers  to 
form  at  the  point  where  the  chemosed  conjunctiva  overlaps  the  limbus 
of  the  cornea.  The  prognosis  is  always  grave.  A  fully  developed  case 
rarely  recovers  without  some  corneal  involvement. 

Treatment. — Treatment  should  be  along  the  same  general  lines 
already  suggested  for  gonorrheal  ophthalmia  neonatorum.  Con- 
tinuously applied  ice  compresses,  especially  for  the  first  thirty-six 
hours,  are  of  great  benefit,  and  should,  according  to  deSchweinitz, 
invariably  be  employed,  provided  the  nutrition  of  the  cornea  is  intact. 
Hosford  and  James^  employ  constant  irrigation  day  and  night  by 
fastening  a  fine  rubber  tube  to  the  forehead  of  the  patient  by  means  of 
adhesive  plaster,  and  allowing  a  stream  of  1 :  15,000  or  1 :  20,000  per- 
manganate solution  to  trickle  constantly  across  the  palpebral  fissure, 
encouraging  the  patient  to  open  the  lids  every  ten  minutes.  In  the 
late  stages  of  the  disease  these  authors  substitute  zinc  (8  grains  to  the 
ounce)  for  the  permanganate. 

In  some  cases  of  marked  chemosis  a  hard  ring  of  swollen  and  in- 
filtrated tissue  surrounds  the  cornea,  which  appears  to  be  lying  in  a 
small  pit.  Radial  incisions  with  a  sharp  Graefe  knife  through  the 
entire  depth  of  the  indurated  tissue  give  excellent  results.  If  the 
chemosis  and  infiltration  return,  it  may  be  necessary  to  repeat  the  in- 
cision on  succeeding  days.  The  scarification  should  be  followed  by  a 
free  boric-acid  irrigation.  Silver  nitrate  should  be  applied  as  pre- 
viously described,  except  that  a  1.5  or  2  per  cent,  solution  should  be 
employed.  Atropin  (4  grains  to  1  ounce)  to  keep  the  pupils  dilated 
and  to  lessen  the  tendency  toward  hyperemia  of  the  uveal  tract  is 
indicated  from  the  onset.  If  only  one  eye  is  affected,  a  BuUer's  shield 
should  be  applied  to  afford  protection  to  the  uninjured  organ.  This  is 
a  glass  shield  having  adhesive  plaster  around  the  edges.  The  plaster 
is  generally  reinforced  by  a  collodion  dressing.  If  the  pain  is  severe, 
morphin  may  be  necessary.  Especial  attention  should  be  directed  to 
the  patient's  general  condition,  as  relapses  are  of  frequent  occurrence 
if  the  general  nutrition  is  not  sustained.  This  is  true  of  children  as 
well  as  of  adults. 

Metastatic  Gonorrheal  Conjunctivitis. — Systemic  gonorrhea  may, 
in  rare  instances,  result  in  ocular  manifestations.  In  these  cases  the 
gonococci  are  probably  carried  as  emboli  to  the  minute  vessels  of 
the  eye.  Indeed,  Galezowski'  has  seen  a  number  of  embolisms  of 
the  central  retinal  arteries  in  gonorrheal  patients,  which  he  considers 

'  deSchweinitz,  G.  E. :   Therap.  Gaz.,  January  15,  1907. 

-  Hosford,  J.  S.,  and  James,  G.  B. :  Lancet,  January  13,  1912. 

^  Galezowski:  Die  ophtlial.  Klinik,  1900,  vol.  iv,  p.  153. 


COMPLICATIONS    AND    XON-GEXITAL    GONORRHEA  415 

to  be  localized  thrombi  of  these  vessels,  due  to  accumulations  of  gono- 
cocci,  and  ^IcKee'  has  demonstrated  the  presence  of  gonococci  in  an 
excised  portion  of  conjunctiva;  the  organisms  were  chiefly  under  the 
epithelium.  A  gonorrheal  septicemia  was  present.  That  this  mode 
of  infection  is  extremely  rare  is  shown  by  Kurka,"  who  in  1902  reported 
the  histories  of  2  cases,  and  stated  that  they  were  the  first  observed  in 
the  Vienna  cUnic  out  of  a  material  of  over  20,000  new  patients  a  year. 
Byers^  beUeves  the  condition  to  be  more  frequent.  Of  the  109  cases 
of  inflammation  of  the  uveal  tract  and  38  cases  of  conjunctivitis  col- 
lected from  the  literature  by  Byers,^  all  but  4  occurred  in  males. 
Burchardt,°  Reyling,''  Panas,^  Cheatham,*  and  Frescoln^  have  re- 
ferred to  cases  in  women.  In  this  large  series  the  youngest  patient 
was  fifteen  and  the  oldest  sixty-eight  years,  the  great  majority  of  cases 
being  between  twenty  and  forty  years  of  age. 

Sytiiptoms. — The  condition  usuallj'  originates  in  a  posterior 
urethritis.  Both  eyes  are  commonly  affected  during  the  first  attack. 
Relapses  are  prone  to  be  unilateral.  Other  compUcations  occurring 
simultaneously,  such  as  arthritis  or  endocarditis,  are  of  frequent 
occurrence.  The  clinical  course  is  characterized  by  irregularity  and 
uncertaint}',  both  as  to  the  severity  of  the  symptoms  and  as  to  the 
extent  to  which  the  parts  are  involved.  The  discharge  is  slight  in 
amount  and  mucoid  in  character. 

Complications,  such  as  affections  of  the  other  coats  of  the  eye,  occur 
in  30  per  cent,  of  the  patients.  Relapses  are  not  uncommon,  and  often 
result  from  a  lighting  up  of  the  original  focus  of  infection.  The  vascu- 
lar coats  of  the  eye  are  the  most  favorable  points  for  lodgment  of  the 
gonococcus.  Metastatic  gonorrheal  inflammation  of  the  optic  nerve 
has  been  described.  Cases  of  dacryo-adenitis,  which  have  been  attrib- 
uted to  systemic  gonorrheal  infection,  differ  in  no  essential  from  the 
ordinary  inflammation  of  the  lacrimal  gland.  Sidler-Huguenin'"  has 
definitely  proved  the  existence  of  metastatic  iridocyclitis. 

Diagrums. — A  diagnosis  of  metastatic  gonorrhea  of  the  conjunctiva 
is  made  with  difficulty.     The  bilateral  character  of  the  disease,  the 

'  McKcc:  Ophthalmology,  1907,  vol.  v,  No.  4,  p.  618. 
'  Kurkii,  A.:  Wien.  kliii.  Woch.,  vol.  xv,  p.  10.32. 

'  Hycr.s,  W.  G.  M.:  Studies  from  the  Royul  Victoria  Hospital,  Montreal,  vol.  ii,  No.  2 
fOphthaliiioloKy,  2),  p.  24. 

*  Hycr.s,  W.  G.  M.:  Lnc.  cil.,  pp.  27  and  73. 

''Uiirchardt:  Charit(^'-,\nnalon,  1X94,  vol.  xix,  p.  2:J7. 

'  Heyling:  LanR.sdalc's  Lancet,  1898,  vol.  iii,  p.  4. 

'  Pana.s:  Hov.  Gi'n.  MM.  et  do  Thcrap.,  IS94,  vol.  Iviii,  p.  l(>i). 

"  Clioalham:  .\rch.  of  Ophthal.,  vol.  xxv,  p.  ."ilO. 

»  Frcsroln,  L.  D.:  Brit.  Med.  Jour.,  Mareh  2.'>,  1911. 

'".Sidlor-Iluguenin:  Arch.  f.  Augenheilk.,  Wiesbaden,  I'.Ml,  Mil.  Kix,  p.  'MG. 


416  GONORRHEA    IN    WOMEN 

absence,  from  the  secretion,  of  gonococci  and  other  bacilU  which  pro- 
duce conjunctivitis,  the  comparative  mildness  of  the  subjective  and 
objective  symptoms,  the  absence  of  any  history  of  gonorrheal  material 
having  come  in  contact  with  the  eye,  the  presence  of  other  manifesta- 
tions of  systemic  gonorrhea  and  of  gonorrhea  in  the  genital  tract,  would 
arouse  suspicion,  and  time  would  soon  reveal  the  true  nature  of  the 
disease  if  it  were  really  one  of  contagious  conjunctivitis. 

Although  ocular  metastatic  gonorrhea  undoubtedly  occurs,  the 
extreme  rarity  of  the  condition  should  be  considered,  and  the  diagnosis, 
unless  made  by  a  skilled  ophthalmologist,  should  be  received  with  the 
utmost  caution.  It  has  been  proved  that  gonococci  may  be  present 
in  the  clear  serous  discharge  from  the  genital  tract,  and  since  the  dis- 
tinction between  the  pathologic  and  the  normal  secretion  is,  at  best, 
often  only  a  relative  one,  this  fact  should  be  borne  in  mind  in  study- 
ing all  cases  believed  to  be  of  systemic  origin. 

Treatment. — The  treatment  of  metastatic  ocular  gonorrhea  differs 
in  no  essential  from  that  usually  employed  for  the  cases  suffering  from 
the  more  common  mode  of  infection,  except  that  as  the  condition  is 
systemic  ami  the  dangers  of  metastasis  occurring  in  other  parts  of  the 
body  are  to  be  considered,  the  patient  should  be  confined  to  bed.  Not 
infrequently  metastatic  ocular  gonorrhea  is  the  initial  symptom  of 
a  gonorrheal  septicemia.  In  this,  as  in  other  metastatic  types  asso- 
ciated with  gonorrhea  elsewhere  in  the  body,  treatment  should  be 
directed  to  the  priginal  source  of  the  infection  and  J,o  the  patient's 
general  condition,  as  reinfection  may  possibly  occur. 

The  deeper  coats  of  the  eye  are  sometimes  attacked  by  the 
gonococcus,  either  as  the  result  of  systemic  or  of  contact  infection. 
Eyre  and  Stewart,^  Miller,-  Shumway,^  Hilbert,''  Krause,^  Pro- 
chaska,*  and  others  have  recorded  the  histories  of  cases  of  gonor- 
rheal iritis,  and  Vandergrift"  reports  the  history  of  a  case  of  gonor- 
rheal choroiditis.  Cause*  has  referred  to  tenonitis,  keratitis,  iridocy- 
clitis, iridochoroiditis,  retinitis,  neuroretinitis,  and  optic  neuritis  of 
gonorrheal  origin.  CampbelP  has  described  a  case  of  neuroretinitis. 
Pes'"  andTerson"  have  reported  cases  of  bilateral  purulent  inflammation 
of  the  tear-sacs  which  they  attributed  to  gonorrhea. 

'  Eyre  and  Stewart:  Lancet,  London,  1909,  vol.  ii,  p.  76. 

'  Miller:    Glasgow  Med.  Jour.,  1910,  p.  202. 

'  Shuinway:  Ann.  Ophthalmology,  1910,  vol.  xi.x,  p.  23. 

*  Hilbert:  Zeit.  f.  prakt.  Aerzte,  1897,  No.  7. 

'  lOause:   Berlin,  klin.  Wochenschr.,  1901,  p.  492. 

"  Prochaska:  Arch.  f.  path.  Anat.  u.  Physiol,  u.  f.  khn.  Medizin,  1901,  p.  492. 

'  Vandergrift,  G.  W. :   Jour.  Amer.  Med.  Assoc,  June  8,  1912,  p.  17.56. 

'  Cause:  Zeit.  f.  Augenheilkunde,  Berlin,  1904,  vol.  xi,  p.  399. 

"  Campbell:  Ann.  d'ocul.,  1896,  vol.  cxv,  p.  47. 

">  Pes:  Die  ophthal.  Klinik,  1898,  vol.  iii,  p.  240.         "  Terson:  Ibid.,  1900,  p.  152. 


COMPLICATIONS   AND    NON-GENITAL   GONORRHEA  417 

Rollet  and  Aurand^  have  conducted  an  interesting  series  of  experi- 
ments upon  rabbits;  thej'  find  that  tlie  gonococcus  appears  to  possess 
a  selective  toxic  action  upon  the  nerve-cells  of  the  retina  and  optic 
nerve.  The  lesions  seem  to  be  due  to  a  toxin,  as  no  gonococci  were  ever 
recovered  from  the  lesions.  Intra-ocular  complications  manifestly  call 
for  the  services  of  the  ophthalmologist,  and  are,  therefore,  not  dealt 
with  in  this  work.  .  The  author  is  of  the  opinion  that  a  skilled  ophthal- 
mologist should,  if  possible,  be  in  attendance  upon  all  gonorrheal 
lesions  of  the  eye;  for  although  the  obstetrician  may  carry  out  the 
routine  treatment  carefully,  complications  may  arise  at  any  time  that 
one  especially  skilled  in  the  study  of  eye  diseases  is  more  capable  of 
dealing  with  satisfactorily  than  are  those  who,  perhaps,  see  such  con- 
ditions only  occasionally. 

»  Rollet  and  Aurand;  Rpv.  Gen.  d'Ophtal.,  1912,  No.  3. 


CHAPTER  XVIII 

GONORRHEAL  SEPTICEMIA,  BACTEREMIA,  AND  TOXEMIA.— 

GONORRHEA  OF  THE  OSSEOUS  AND  CIRCULATORY 

SYSTEMS 

GONORRHEAL  SEPTICEMIA,  BACTEREMIA,  AND  TOXEMIA 
That  gonorrhea  can  no  longer  be  regarded  as  a  purely  local  disease 
modern  research  has  amply  proved.  Much  of  this  work  has  been  done 
in  France.  The  French  use  the  term  "gonohemia"  to  describe  the 
condition  when  the  circulatory  system  is  involved.  By  bacteriologic 
experiments  it  has  been  shown  that  the  gonococcus  grows  best  in  a 
medium  that  contains  blood  or  its  derivatives.  It  is  not  surprising, 
therefore,  to  find  that,  under  certain  circumstances,  virulent  gono- 
cocci  may  be  found  in  the  circulating  blood.  Thayer  and  Blumer^ 
were  the  first  to  demonstrate  these  microorganisms  in  pure  culture  in 
the  blood-stream  during  life.  Since  then  numerous  observers  have 
recovered  the  organisms  from  the  blood,  and  gonorrheal  septicemia  has 
become  an  established  clinical  entity.  Three  theories  accounting  for 
the  existence  of  general  gonorrheal  infection  have  been  advanced: 
The  first  is  that  the  infection  occurs  through  the  blood;  the  second, 
that  it  occurs  through  the  lymphatic  system;  and  the  third,  that  the 
results  are  due  to  the  presence  of  toxins.  It  is  likely  that  all  three 
channels  are  sometimes  factors  in  the  causation.  Hematogenous  in- 
fection is  probably  the  most  frequent.  The  exact  part  played  by  the 
lymphatics  in  general  gonorrheal  infection  is  still  undetermined,  al- 
though Uysing^  and  others  have  demonstrated  the  presence  of  the 
gonococcus  in  the  lymph-stream.  Undoubtedly,  gonorrheal  toxemia 
exists,  but  the  fact  that  the  specific  microorganism  cannot  always  be 
demonstrated  in  a  certain  lesion  does  not  by  any  means  prove  the  ab- 
sence of  a  septicemia,  as,  apart  from  the  difficulty  often  encountered 
in  the  bacteriologic  and  microscopic  demonstration  of  these  micro- 
organisms, it  has  been  amply  proved  that  the  gonococci  in  many  in- 
stances disappear  from  encapsulated  fluid  after  varying  intervals. 
This  peculiarity  of  the  gonococcus  doubtless  accounts  for  the  many 
cases  in  which  the  specific  microorganism  cannot  be  demonstrated  in 

'  Thayer  and  Blumer:  Arch,  de  m^d.  exper.  et  d'anat.  path.,  Paris,  November,  1895; 
also  Johns  Hopkins  Hosp.  Bull.,  1896,  vol.  vii,  p.  57. 
^Uysing:  Inaug.  Dissert.,  Kiel,  1900. 

41S 


GONORRHEAL    SEPTICEMIA,    BACTEREMIA,    AND    TOXEMIA  419 

the  fluid  from  cases  of  arthritis  and  endocarditis,  etc.  Zieler^  believes 
that  all  general  gonorrheal  infections  begin  as  septicemias,  but  that 
the  organisms  often  disappear  rapidly  from  the  blood-stream  or  are 
present  onlj-  in  such  small  numbers  that  their  demonstration  is  almost 
impossible. 

From  a  study  of  the  recorded  cases  it  would  seem  that  toxemias 
are,  as  a  rule,  less  severe  than  septicemias.  Probably  a  considerable 
proportion  of  certain  of  the  mild  lesions,  such  as  the  mild  skin  erup- 
tions; lesions  of  the  nervous  system,  peripheral  and  central;  mild 
cases  of  optic  neuritis  and  retinitis,  and  even  in  some  instances  con- 
junctivitis, as  well  as  the  various  other  better  known  conditions,  may 
be  due  to  toxemias. 

Despite  the  numerous  recorded  cases,  gonorrheal  septicemia  is 
relatively  infrequent  when  we  consider  the  prevalence  of  genital  gon- 
orrhea, although  Thayer  observed  10  cases  within  a  period  of  six  years 
in  the  Johns  Hopkins  Hospital.  Cholzow,-  Margan,^  Prochaska^  (3 
cases),  Himmelheber,"  Krause*'  (2  cases),  Dieulafoj-,"  Sowinsky,^  Faure- 
Beaulieu,^  Wynn,'"  Weitz,"  Zieler,'-  Rey,''  Rotky,'^  Hodara,  Osman, 
Izzit  and  Chevet,'^  Thevenot  and  Michel,^^  and  Moorhead"  have 
recorded  cases  in  which  undoubted  gonococci  have  been  recovered 
from  the  circulating  blood-stream.  Doubtless  many  cases  are  over- 
looked, owing  to  the  fact  that  but  little  attention  has  been  paid  to  this 
condition,  and  also  that  gonorrheal  septicemia  often  becomes  manifest 
after  the  acute  symptoms  of  the  original  infection  have  disappeared; 
indeed,  in  many  cases  when  the  bacteriologic  nature  of  the  septicemia 
has  been  cstabhshed  beyond  question,  it  has  been  only  with  the  great- 
est difficulty  that  the  specific  microorganisms  have  been  demonstrated 

'  Zicler,  K.:  Mediz.  Klinik,  Fobruary  11,  1912. 

'  Cholzow,  B.  N.:  Zeitschr.  f.  Urologic,  1911,  vol.  v,  No.  12. 

»  Margan:  La  Sem.  Mod.,  1910,  p.  261. 

<  Prochaska:  Virchow's  Arch.,  1901,  vol.  clxiv,  p.  492;  also  Arch.  f.  path.  .\nal.  u. 
Physiol,  u.  f.  klin.  Medizin,  1901,  p.  492. 

'  Himmelhebcr:   Med.  Klinik,  1907,  No.  96. 

«  Krausc,  P.:  Berlin,  klin.  Wofhonschr.,  May  9,  1904,  No.  19,  p.  494. 

'  iJii'ulafoy:  La  Scni.  Mod.,  1909,  p.  238. 

« .Sowin.sky,  S.  W.:  Dissert.  St.  Peter-sburp,  1901. 

'  Faurc-Beauheu:  Thdsede  Paris,  1900;  rcf.  La  Sem.  Mod.,  1907,  p.  30. 

'"  Wynn:  Lancet,  February  11,  1905,  p.  352. 

"  Weitz:  Mediz.  Klinik,  February  4,  1912. 

'=  Zieler,  T. :  Mediz.  Klinik,  February  1 1,  1912. 

"Key,  C:  Bull.  S<ic.  mod.  d'h6p.  de  Lyon,  1912,  vol.  x,  p.  315;  also  Lyon  Mi'd., 
1912,  vol.  cxviii,  p.  11(19. 

'«  Rotky,  K.:  Wion.  klin.  Wochen.schr.,  1912,  No.  3,  p.  1187. 

"  llodara,  Osman,  Izzet  and  Chovet:  Gaz.  M6(\.  d'Orient,  .June,  1911,  p.  143. 

'•Thevenot,  L.,  and  Michel,  P.:  La  Province  M(5d.,  1912,  No.  20,  p.  228. 

"  Moorhcad,  G.  L:   Med.  Presse,  1912,  vol.  xciii,  p.  355. 


420  GONORRHEA    IN    WOMEN 

in  the  original  lesion.  A  further  source  of  error  is  the  well-known 
difficulty  with  which  gonococci  are  grown  upon  an  artificial  medium, 
so  that  unless  the  bacteriologist  who  takes  the  blood-cultures  employs 
a  medium  especially  adapted  to  the  growth  of  the  gonococcus,  no  cul- 
tures will  be  oljtained.  A  further  difficulty  in  establishing  the  etio- 
logic  relationship  of  the  gonococcus  in  these  cases  is  the  fact  that  the 
microorganisms  are  usually  present  onh^  in  small  numbers. 

Septicemia  generally  follows  gonorrhea  of  the  genital  organs,  as 
this  is  the  most  frequent  locality  for  the  infection  to  occur.  Brehmer,i 
Hoeck,^  Widmark,^  Chartres,*  Stevens,^  Stephenson,"  Hock,''  and  others 
have,  however,  reported  the  histories  of  cases  of  general  septicemia  that 
followed  a  gonorrheal  eye  lesion.  Gonorrheal  septicemia,  bacteremia, 
and  toxemia  are  far  more  frequent  among  males  than  among  females. 
In  a  large  proportion  of  cases  the  gonococci  have  disappeared  from  the 
anterior  urethra,  the  site  of  the  infection  being  the  prostate  or  the 
seminal  vesicles.  Thus  Ulmann^  reports  5  fatal  cases,  in  4  of  which 
the  focus  of  infection  was  a  prostatic  abscess.  Children  and  pregnant 
women  seem  to  offer  a  more  fertile  soil  for  the  development  of  gonor- 
rheal septicemia  than  do  non-gravid  females.  KimbalP  has  recorded 
the  histories  of  8  cases,  in  none  of  which  the  patients  were  over  three 
months  of  age;  6  proved  fatal.  The  mode  of  entrance  of  the  gono- 
coccus to  the  circulating  blood  has  not  as  yet  been  definitely  deter- 
mined. Some  loss  of  continuity  in  the  infected  mucosa  is  the  probable 
entrance  point  in  the  majority  of  cases.  Leede'"  reports  the  history  of 
a  case  in  which  he  believes  a  chancre  was  the  point  of  entrance  for  the 
gonococci.  This  author  is  of  the  opinion  that  the  gonococci  were 
carried  from  the  chancre  by  the  lymphatics  and  conveyed  thence  to 
the  blood.  Purulent  gonorrheal  arthritis,  fatty  degeneration  of  the 
heart,  and  other  evidences  of  a  general  infection  were  present.  Leede 
quotes  a  somewhat  similar  case,  the  history  of  which  has  been  recorded 
by  Jadassohn.  The  theory  of  loss  of  continuity  is  well  borne  out  by  a 
study  of  the  reported  cases  that  have  come  to  autopsy,  in  nearly  all  of 
which  a  local  focus  of  suppuration,  in  the  deep  urethra,  the  deep  peri- 

'  Brehmer,  C:  Deut.  med.  Wochenschr.,  Leipzig  and  Berlin,  1905,  vol.  xxxi,  p.  64. 
^  Hoeck:  Jahresb.  der  Ophth.,  1894,  p.  531. 
3  Widmark:  Rev.  G(;n.  d'ophtalmologie,  April  30,  1888. 
*  Chartres:  These  de  Bordeaux,  1897,  p.  27. 
'Stevens:  Ophthalmic  Record,  November,  1905. 
«  Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  143. 
'Hock,  H.:    "Ein  Beitrag  zur  Arthritis   blennorrhoica,"   Wien.  kliu.   Wocl;.,    1893, 
vol.  vi,  p.  736. 

«  Ulmann:  Deut.  Arch.  f.  klin.  Med.,  1901,  vol.  Ixix,  p.  309. 
»  Kimball,  R.  B.:  Med.  Record,  November  14,  1903,  p.  461. 
'»  Leede:  Munch,  med.  Woch.,  February  28,  1911,  p.  466. 


GONORRHEAL    SEPTICEMIA,    BACTEREMIA,    AND    TOXEMIA  421 

urethral  tissues,  or  the  pelvis,  has  been  present.  This  focus  may  in 
some  instances  be  extremely  small,  as  in  a  case  related  by  Thaj^er,^ 
in  which  the  only  etiologic  factor  was  a  prostatic  abscess  a  few  centi- 
meters in  diameter.  Zieler-  states  that  anything  that  has  a  tendency 
to  aggravate  an  acute  gonorrheal  catarrh  favors  sepsis,  /.  e.,  trauma, 
especially  from  unskilful  instrumentation,  alcoholic  or  venereal  ex- 
cesses, menstruation,  pregnancy,  ill-advised  treatment,  and  general 
constitutional  diseases,  such  as  tuberculosis,  diabetes,  or  any  condition 
that  lowers  the  general  vitality.  Kimball,^  after  carefully  reviewing 
the  histories  of  10  cases  of  septicemia  that  occurred  in  infants  or  young 
children,  suggests  the  possibility  of  the  condition  occasionally  arising 
from  a  stomatitis  neonatorum,  as  in  8  of  his  cases  no  gonococci  could 
be  demonstrated  in  the  genital  tract.  Taking  into  consideration  the 
difficulty  often  encountered  in  recovering  the  gonococci  from  the 
vagina  in  chronic  cases,  such  a  route  of  infection,  although  possible, 
should  be  regarded  with  caution. 

Systemic  infection  may  arise  in  any  case  of  gonorrhea,  no  matter 
how  mild,  but,  as  has  previoush'  been  stated,  the  malady  generally 
appears  during  the  chronic  stage  of  the  original  infection,  and  is  often 
accompanied  by  a  cessation  of- local  symptoms;  although  Irons'* 
reports  the  histor\'  of  a  case  in  which  the  septicemia  developed  within 
seven  da5's  of  the  appearance  of  the  initial  attack.  Mixed  infection  is 
not  uncommon,  the  associated  organisms  most  frequently  present  being 
the  colon  bacillus,  the  streptococcus,  the  staphylococcus,  or  some  of 
the  other  common  pyogenic  microorganisms.  Among  10  cases  studied 
by  Thayer,''  in  all  of  which  gonococci  were  positively  identified  by 
cultures  from  blood  intra  vikim,  from  local  lesions  at  necropsy,  or  by 
both  methods,  3  showed  a  mixed  infection.  I^ofaro"  has  studied  the 
question  of  whether,  in  ordinary  cases  of  genital  gonorrhea,  the  micro- 
organisms are  to  be  found  in  the  blood.  Sixty-seven  cases  were 
examined,  and  the  specific  microorganisms  were  fcjund  in  the  blood  of 
'■V.h  These  were  mostly  cases  of  urethritis,  either  acute  or  chronic. 
In  nf)ne  f)f  the  acute  cases  were  the  gonococci  demonstrated  in  the 
circulation.  Lofaro  believ^es  that  it  is  only  when  extremely  virulent 
bacteria  are  i)resent,  or  when  the  soil  is  especially  suitable,  that  tlie 
gonococci  enter,  or,  at  all  events,  thrive  in  the  blood.  Further  in- 
vestigation on  this  subject  is  required,  as  it  has  providusly  Ix-cii  tlio 

'   Thayer:   .Aiiicr.  .Jour.  Mod.  Sci.,  lilO.i,  p.  ~'^'l. 

■  Zieler.  \{.:   M<'<l.  Kliriik,  Hcrliti.  Keluimry,  lOTi,  vol.  viii,  No.  li. 

Kiinl.aM,  H.  M.:   M.'d.  Keconl.  New  York,  Noveinhor  14,  I'.tO:^,  p.  701. 
'  Irons:  .\l>.s|.  .\rner.  .(our.  I'rolony.,  I'.MO.  vol.  vi,  p.  240. 
•Thayer:  .\mer.  .lour.  Meil.  Sci.,  Novemlx'r,  I'.M)."). 
•  l.ofaro,  I'".:   II  I'olielin.,  Kebriiury,  1011. 


422  GONORRHEA    IN   WOMEN 

common  belief  that  the  gonococci  do  not  flourish  in  the  general  cir- 
culation under  ordinary  conditions,  a  conclusion  that  seems  to  be  borne 
out  by  the  clinical  fact  that  in  many  cases  of  gonorrhea  no  metastatic 
complications  are  encountered. 

Symptoms. — In  gonorrheal  septicemia,  bacteremia,  or  gonotoxemia 
no  organ  or  tissue  in  the  body  is  immune,  although  the  microorganism 
appears  to  possess  a  special  predilection  for  the  various  serous  mem- 
branes, such  as  the  endocardium,  pericardium,  pleura,  peritoneum, 
meninges,  and  synovial  tissues.  As  a  result,  the  symptoms  may  vary 
widely  in  different  cases. 

As  has  been  mentioned  elsewhere,  all  gonococcal  lesions  that  are 
distant  from  the  point  of  original  infection,  such  as  arthritis,  endocardi- 
tis, etc.,  are  manifestations  of  a  general  infection.  Many  of  such  cases 
can,  however,  be  classed  under  the  heading  of  the  so-called  metastatic 
infections,  that  is,  the  gonococci  or  the  toxins  are  carried  to  a  particular 
location  and  there  produce  local  symptoms,  and  are  not  accompanied 
by  the  usual  evidences  of  what  is  generally  termed  septicemia,  bacter- 
emia, or  toxemia.  Such  cases  are  discussed  under  a  separate  heading. 
On  the  other  hand,  as  would  be  expected,  many  true  septicemias  are 
accompanied  by  an  arthritis  or  other  local  conditions. 

Usually  the  symptoms  of  a  general  gonococcal  infection  are  simi- 
lar to  those  produced  by  pyogenic  microorganisms  in  general.  The 
systemic  infection  is  often  ushered  in  by  a  cessation  or  subsidence  of 
local  symptoms.  At  the  onset  systemic  disturbances,  such  as  malaise, 
feverishness,  headache,  nausea  or  vomiting,  and  backache,  and  other 
manifestations  of  constitutional  infection,  may  be  present.  The  initial 
symptom  of  the  attack  is  often  a  chill,  which  may  be  followed  by  high 
temperature  of  irregular  range,  profuse  sweats,  delirium,  stupor  passing 
into  coma,  and  death.  Smith^  and  others  have  called  attention  to  the 
marked  fluctuations  in  temperature  that  may  be  present.  The  similar- 
ity to  typhoid  fever  in  some  instances  is  striking,  as  exemplified  in  the 
cases  reported  by  Dieulafoy,- Irons, 'and Thayer.^  An  eruption  appear- 
ing over  the  abdomen,  thorax,  thighs,  arms,  or  neck  may  be  an  early 
symptom.  It  may  be  polymorphic,  and  at  first  is  often  rose  colored, 
slightly  elevated,  and  disappears  on  pressure.  It  appears  in  the  form 
of  crops,  later  not  infrequently  becoming  papular  and  suggestive  of 
syphilis,  or  resembling  the  eruption  produced  by  the  ingestion  of  bal- 
samic drugs.     Gonococci  have  been  demonstrated  in  the  eruption. 

'  Smith,  J.  T.:  Cleveland  Med.  Jour.,  1911,  No.  10,  p.  SIO. 
2  Dieulafoy:  Internal.  Clinics,  vol.  iii,  nineteenth  series,  p.  59. 
'  Irons:  Abst.  Amer.  Jour.  Urology,  1910,  vol.  vi,  p.  '2l)4. 
*  Thayer:  Amer.  Jour.  Med.  Sol.,  November,  1905. 


GONORRHEAL    SEPTICEMIA,    BACTEREMIA,    AND    TOXEMIA  -123 

Figueras^  refers  to  a  case  of  gonorrheal  septicemia  that  had  been  mis- 
taken for  malaria.  Jochmann^  states  that  the  spleen  is  usually  en- 
larged, and  that  albuminuria  is  often  present.  ChevreP  has  reported 
a  case  in  which  the  fever  was  markedly  intermittent.  The  fever  may 
be  high  and  irregular,  or  the  temperature  may  be  slightly  elevated  and 
continuous  throughout,  depending  upon  the  virulence  of  the  micro- 
organism and  the  resisting  power  of  the  patient.  Mixed  infections, 
especially  when  the  streptococcus  is  present,  are  usually  productive  of 
the  most  severe  symptoms.  Padula^  has  called  attention  to  the  mild 
continued  fever  that  is  sometimes  present  in  clinically  uncomplicated 
cases  of  gonorrhea  of  the  genito-urinary  tract,  and  suggests  that  these 
may  be  due  to  a  mild  systemic  infection.  Indeed,  Zieler^  states  that 
in  mild  cases  the  septicemia  is  frequently  overlooked.  Profuse  sweats 
are,  as  a  rule,  present.  Sudamina  may  result.  The  pulse  becomes 
rapid  and  weak  and  often  dicrotic.  The  heart-sounds  become  feeble. 
The  first  sound  is  especially  weak,  and  resembles  the  second.  Nausea 
or  vomiting  may  be  a  marked  symptom  or  may  be  entirely  absent. 
Diarrhea  is  generalh'  present,  although  it  is  not  a  constant  symptom. 
As  the  disease  progresses  weakness,  anemia,  loss  of  weight,  and  in 
severe  cases  low,  muttering  delirium,  subsultus  tendinum,  carphologia, 
or  coma-vigil  may  be  observed.  Examination  of  the  blood  reveals 
the  presence  of  the  gonococcus  if  the  case  be  one  of  septicemia.  Weitz" 
has  reported  the  history  of  an  interesting  case  in  which  acute  atrophy 
of  the  liver  occurred.  Jaundice  appeared  three  days  before  death. 
Leukocytosis  is  always  present.  The  white  blood-corpuscles  vary 
in  number  from  10,000  to  30,000  or  more.  A  differential  count  in 
Dieulafoy's^  case  showed  the  following:  Polynuclears,  71  per  cent.; 
lymphocytes,  18  per  cent.;  large  mononuclears,  10  per  cent.;  eosino- 
philes,  1  percent.;  white  blood-corpuscles,  10,000;  hemoglobin,  0.42 
percent.  Asa  result  of  the  presence  of  living  gonococci  in  the  general 
circulation,  various  other  complications  are  frequently  present.  Of 
these,  arthritis  is  perhaps  the  most  common.  Faure-Bcaulieu'*  records 
this  condition  as  occurring  26  times  in  a  series  of  34  cases  of  gonorrheal 
septicemia.     Cole"  observed  endocarditis  1 1  times  in  a  series  of  20  cases 

'  KiRUor.os:  La  Pronsa  Mo  lica,  March  1"),  1111 1. 

'.lochmann:   Berlin,  klin.  Woch.,  March  4,  1912. 

'  Chevrel,  !•".:  Progr6i  Mel.,  Pari.s,  1912,  vol.  .x.wiii,  p.  281. 

'  Padiila:   Fobbrc  infcctiva  da  viru.s  blennorrliaKico,  IJomo,  Svo,  1S92. 

'  Zi.'lor,  K.:   Mc-I.  Klinik,  rcl)ruary  11,  1912 

'■  Wcitz;  Med.  Klinik,  1912. 

'  Dieulafoy:  Internal.  Clinics,  vol.  iii,  nineteenth  .serio.s,  p.  Gl. 

»  laure-Beaiilieti:  Thft^ede  Paris,  1906;  ref.  in  La  Sem.  M6d.,  1907,  p. :«). 

"Cole,  H.  I.:  O.sler's  Modern  Medieine,  vol.  iii,  p.  91,  Philadelphia,  1907. 


424  GONORRHEA    IN   WOMEN 

of  gonorrheal  septicemia.  Other  complications  often  occur.  The 
prognosis  depends  largely  upon  the  complications  that  are  present. 
Mixed  infections  are,  as  a  rule,  the  more  virulent,  the  most  fatal  micro- 
organisms being  the  streptococcus.  The  prognosis,  even  in  the  mildest 
cases,  should  be  guarded,  for  severe  or  lethal  complications  may  arise 
at  any  time.  Relapses  are  not  infrequent.  Chartres,^  Rothrock,- 
Stevens,^  Tic  and  Sigaud,^  Stephenson,^  and  many  others  record 
deaths  from  this  condition.  Of  Cole's*  collected  series  of  29  cases,  12 
died,  16  recovered,  and  in  1  the  result  was  not  stated.  Excellent  pa- 
pers on  general  gonorrheal  infection  by  Schneider,'  v.  Hoffman,**  and 
Sturgis^  have  appeared. 

Diagnosis. — The  diagnosis  of  gonorrheal  septicemia  depends  en- 
tirely upon  the  demonstration  of  the  specific  microorganism  in  the 
circulating  blood-stream.  It  should  be  remembered  that  in  the 
majority  of  cases  the  primary  lesion  is  a  chronic  one,  or  that  it  may 
have  subjectively  disappeared.  General  gonorrheal  infections  cannot 
be  positively  differentiated  from  other  forms  of  infection  unless  a 
bacteriologic  examination  of  the  blood  is  made. 

Treatment. — This  consists,  when  possible,  of  the  eradication  of  the 
disease  from  its  primary  source,  for  reinfection  may  occur.  A  septi- 
cemia in  the  female  generally  originates  from  an  intrapelvic  lesion, 
often  from  a  salpingitis.  As  regards  the  necessity  for  immediate 
operation  the  surgeon  must  be  governed  largely  by  the  condition  of 
the  individual  patient.  Rest  in  bed  and  a  sustaining,  easily  assimil- 
able, alcohol-free  diet  are  indicated.  Cold  packs  or  baths  may  be 
employed  to  combat  pyrexia.  The  bowels  should  be  regulated,  and 
the  use  of  the  bed-pan  enforced.  As  pneumonia  and  pleurisy  are  not 
uncommon  complications,  a  woolen  jacket  should  be  worn.  Strych- 
nin is  not  infrequently  required,  as  cardiac  fatigue  often  occurs;  in 
some  cases  opium  is  necessary  to  relieve  pain.  In  the  majority  of 
cases  symptomatic  treatment  is  indicated.  Zieler'"  recommends  in- 
travenous injections  of  coUargol.  Marchildon"  states  that  the  method 
of  injection  is  similar  to  that  employed  for  salvarsan.     A  1  per  cent. 

'  Chartres,  E. :  These  de  Bordeaux,  1S96,  p.  27. 

"-  Rothrock,  J.  L.:  St.  Paul  Med.  Jour.,  1911,  vol.  xiii,  p.  494. 

'  Stevens,  E.  W.:  Ophthalmic  Record,  November,  1905. 

'  Tic  and  Sigaud:  Lyon  Med.,  1911,  vol.  cwi,  p.  93.3. 

'  Stephen.son,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  143. 

«  Cole,  R.  I.:  Osier's  Modern  Medicine,  vol.  iii,  p.  94,  Philadelphia,  1907. 

'  Schneider:  Zeit.  f.  Heilk.,  1901,  No.  10, 

»  v.  Hoffman:  Centralbl.  f.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1903,  vol.  vi,  No.  7. 

'  Sturgis:  St.  Louis  Courier  of  Med.,  July,  1901. 

'"  Zieler,  K.:  Med.  Klinik,  February  11,  1912. 

"  Marrhildon,  J.  W.:  Jour.  Missouri  .State  Med.  Assoc,  November.  1912,  p.  141. 


BOXE    AND    JOINT    LESIONS    PRODUCED    BY    GONORRHEA  425 

solution  of  coUargol  is  prepared  in  physiologic  salt  solution,  and  10  c.c. 
of  this  is  injected  into  a  vein  of  the  arm  daily  for  three  or  four  days. 
WTien  the  gonococcidal  properties  of  collargol  are  considered  (see 
Chapter  XX)  and  the  necessary  dilution  that  must  occur  in  the  blood, 
this  would  not  appear  to  be  a  very  useful  form  of  treatment.  Com- 
plications should  be  guarded  against,  and  when  they  arise,  require 
especial  treatment..    Pus  should  be  evacuated  as  soon  as  possible. 

BONE  ap;d  joint  lesions  produced  by  gonorrhea 
The  relationship  between  arthritis  and  gonorrhea  was  recognized 
by  many  of  the  early  writers.  The  work  of  Brande'  is  perhaps  the 
clearest  and  most  convincing  of  the  earlier  writings  on  the  subject. 
Lindermann-  was  the  first  to  demonstrate  the  presence  of  gonococci  in 
pure  culture  from  a  case  of  arthritis,  and  thus  positively  established 
the  clinical  existence  of  this  condition.  Similar  results  were  obtained 
by  Hock'  in  the  following  year. 

Gonorrheal  Arthritis. — Gonorrheal  arthritis,  like  gonorrhea  of  the 
heart,  lungs,  pleuia,  or  other  structures  remote  from  the  original 
point  of  infection,  is  merely  a  local  manifestation  of  a  general  infection, 
the  gonococci  being  transmitted  by  the  blood-stream  from  the  primary 
focus  to  other  areas  in  the  body,  and  there  finding  lodgment  and  pro- 
ducing their  characteristic  lesions.  Just  why  certain  organs  and  joints 
are  .selected  in  a  given  case  is  not  known.  The  experiments  of  Lofaro, ' 
which  have  previously  been  referred  to,  are  of  particular  interest  in 
this  connection.  This  observer  has  shown  that  in  a  considerable  pro- 
portion of  cases  of  chronic  gonorrhea  in  which  only  genital  lesions  are 
apparently  present  gonococci  may  be  recovered  from  the  circulating 
blood.  That  a  loss  of  continuity  at  the  site  of  the  original  infection  is  a 
predisposing  factor  to  a  gonorrheal  septicemia  seems  to  be  well  estab- 
lished, but  this  alone  is  not  sufficient  evidence  to  explain  the  causation 
of  a  general  infection,  as  arthritis  is  undoubtedly  jiresent  in  many 
cases  in  which  no  gonococci  can  be  demonstrated  in  the  circulation  at 
the  time  when  the  articular  lesions  t)ecome  manifest,  l.ofaro  explains 
this  circumstance  on  the  grounds  of  individual  susceptil)iHty  of  the 
patient  and  the  degree  of  virulence  of  the  i)articular  micnxM-ganism. 
In  the  majority  of  cases  the  gonococci  have  probal)ly  disai)peare(l  from 
the  general  circulation  by  the  time  the  articular  symptoms  have  be- 
come manifest.     Whatever  the  cause,  the  fai'l   tliat  cases  of  arlhrilis 

'  Uraiidc:   .\rcli.  gC-ii.  dc  iiicd.,  Paris,  IS.'vl,  vol.  ii,  p.  2.57. 

■  Linilcrinann:  Beit.  ■/,.  .\iiKonh.,  MainburK  and  Lcipzii:,  lSi)2,  p.  '.W. 

^  Mock:  WicM.  klin.  Wofli.,  IS'.Ki.  vol.  iv.  p  7:!!). 

'  Lofaro,  I\:    II  I'olicliiiico.  IVI.iUMry.  I'.ill. 


426  GONORRHEA    IN    WOMEN 

or  endocarditis,  etc.,  are  in  reality  general  infections  should  not  be  lost 
sight  of,  as  the  prognosis  and  treatment  are  largely  dependent  upon  this 
point. 

Gonorrheal  arthritis  is  a  metastatic  infection,  and  may  follow  pri- 
mary gonorrhea  of  any  organ  in  the  body,  or,  less  frequently,  may  be 
caused  by  a  toxemia.  It  generally  occurs  secondarily  to  urethritis, 
vulvovaginitis,  or  ophthalmia,  and  usually  becomes  manifest  during 
the  chronic  stage  of  the  original  infection.  Griffon'  states  that  in  ex- 
ceptional cases  articular  symptoms  may  precede  the  subjective  symp- 
toms at  the  original  site  of  the  infection.  This,  however,  is  very  rare. 
Resnikow-  has  described  a  case  in  which  a  sixteen-year-old  girl  de- 
veloped urethritis  and  arthritis  four  days  after  marriage  to  a  man 
suffering  from  gonorrhea.  Arthritis  secondary  to  eye  lesions  has  been 
described  by  Lucas,''  Fenwick,^  Deutschmann,^  Hoeck,*^  Haushalter,^ 
Paulsen,*  Altland,^  Stephenson, i°  and  others.  With  the  onset  of  ar- 
ticular symptoms  the  manifestations  of  the  primary  lesion  generally 
subside,  the  discharge  and  pain  decreasing.  This  does  not  indicate 
that  the  primary  lesion  is  cured,  as  symptoms  from  it  usually  recur  as 
the  arthritis  improves. 

According  to  some  authorities,  trauma  is  a  frequent  predisposing 
factor  to  gonorrheal  arthritis.  The  arthritis  itself  is  prone  to 
recur,  and  one  attack  apparently  predisposes  to  subsequent  seizures. 
Recurrence  frequently  follows  reinfection  or  the  lighting  up  of  a 
chronic  lesion. _  Slight  trauma,  such  as  is  inflicted  by  the  passage 
of  a  sound  or  too  vigorous  treatment,  is  often  followed  by  a 
recurrence  of  joint  trouble.  Arthritis  may  occur  at  any  time  during 
the  course  of  a  gonorrhea,  but  is  most  often  encountered  about  two  to 
eight  weeks  after  infection — in  other  words,  during  the  chronic  stage 
of  the  primary  disease.  The  disease  may  be  monoarticular  or  poly- 
articular, the  latter  being  the  most  frequent  condition.  JuUien" 
reports  348  cases,  of  which  143  were  monoarticular.     Baer'^  states 

'  Griffon:  Quoted  by  Dieulafoy:  Text-l)ook  of  Mciliciiie,  vol.  ii,  p.  1996;  Bailliere, 
Tindall,  and  Cox,  London,  1910. 

-  Resnikow:  Quoted  by  Cole;  Osier's  Modern  Medicine,  1907,  vol.  iii,  p.  103. 
'  Lucas,  R.  C. :  Brit.  Mod.  Jour.,  February  28,  July  11,  and  October  10,  1885. 
•>  Fenwiek,  R.  G.:  Brit.  Med.  Jour.,  October  31,  1885. 

*  Deutschmann:  Von  Graefe's  Arch.  f.  Ophthal.,  1890,  vol.  xxxvi,  p.  109. 

'^Hoeck:  Jahresb.  der  Ophthal.,  1894,  p.  531:  also  Wien.  kUn.  Woch.,  October  12, 
1893,  p.  736. 

'  Haushalter:  La  Sem.  M6d.,  1895,  vol.  xv,  p.  380. 

*  Paulsen:   Miinch.  med.  Wochenschr.,  August  28,  1900. 
»  Altland:  Klin.  Monatsbl.  f.  Augenheilk.,  April,  1902. 

'"  Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  142 

".Jullien:  Quoted  by  E.  Finger:  Wood's  Med.  and  Surg.  Monographs,  New  York, 
1889,  p.  294. 

'-  Baer,  A.  N.:  Amer.  Jour.  Dermat.,  vol.  xii,  1908,  p.  14. 


BONE    AND    JOINT    LESIONS    PRODUCED    BY    GONORRHEA  427 

that  in  66  per  cent,  of  all  cases  more  than  one  joint  is  involved.  Cole^ 
cites  the  histories  of  50  cases,  all  but  3  of  which  were  polyarticular. 
The  statistics  of  Markheim-  and  of  Bloodgood^  show  that  the  disease 
was  polyarticular  in  from  56  per  cent,  to  60  per  cent,  of  cases.  Blood- 
good,  however,  states  that,  on  admission  to  the  hospital,  more  than  one 
joint  was  affected  in  only  11  per  cent,  of  cases.  In  the  early  stages 
more  than  one  joint  is  usually  attacked;  later  the  disease  exhibits  a 
tendency  to  be  monoarticular. 

The  combined  statistics  of  Northrup,  Finger,  and  Bennecke,^  com- 
prising 704  cases,  show  that  the  joints  were  involved  in  the  following 
order  of  frequency : 

Northrop  Finger          Bensecke  Total 

Knee 91  136  31  258 

Ankle 57  59  9  125 

Wrist 27  43  0  76 

Elbow 18  25      •  10  .53 

Shoulder 16  24  4  44 

Hip 16  18  8  42 

Temporomaicillary 2  14  16 

Small  joint.s  of  foot 40  6  46 

Heel  ami  toes 21  .  .  21 

Small  joints  of  hand 11  35  4  50 

Sternoclavicular -3  3 

Other  articulations 21  21 

The  wrist  is  attacked  more  frequently  in  women  than  in  men.  In 
some  cases  the  disease  may  originate  as  a  monoarticular  lesion  and 
subsequently  attack  other  joints.  Like  gonorrheal  septicemia,  gon- 
orrheal arthritis  is  more  frequent  in  men  than  in  women,  and,  indeed, 
is  seldom  observed  in  females  except  during  pregnancy  or  the  puer- 
perium.  Children  are  by  no  means  immune,  joint  lesions  frequently 
following  a  vulvovaginitis.  Holt'"  states  that  a  pyemic  arthritis  in  a 
young  infant  is  more  frequently  due  to  the  gonococcus  than  to  any 
other  micnxirganism. 

In  1S99  Lucas"  was  able  to  collect  the  histories  of  23  cases  of  gon- 
oirheal  joint  lesions  occurring  in  infants  or  young  children,  all  of  which 
were  secondary  to  ophthalmia.  Of  223  cases  of  arthritis  reported  by 
Weiss,'  117  occurred  in  men,  76  in  women,  and  30  in  children.  Of 
Xorthrup's  252  cases,  230  were  men  and  only  22  woiikmi.     Of  50  cases 

'  Cole:  Osier's  Modern  Medicine,  1907,  vol.  iii,  p.  103. 

'Markheim:  Quoted  by  Young,  J.  K.:  Manual  and  Atlas  of  Orth.  Surgery,  I'liila- 
(Iclphla,  1905,  p.  .528. 

'  Hloodgood:  (Quoted  bv  Young,  J.  K.:  Manual  and  Atla.s  of  Orlli.  Surgery,  I'liila- 
<lelphia,  1905,  p.  .528. 

'Northrup,  Finger,  and  Hennecke:  (iuolcMl  by  Young,  .1.  K.:  Manual  and  Alias  of 
Orthopedic  Surgery,  rhiladelphia,  1905,  p.  52'.l. 

'  Holt:  Trans".  Ni'W  York  Acad.  Med.,  1905. 

«  Luca.s,  R.  C:  Mcd.-Chir.  Traas.,  published  by  the  Hoy.  Meil.  and  Cliir.  Soc  ,  l,«in<l(in, 
vi)l.  Ixxxii  (second  series,  vol.  Ixiv),  1S!)9,  p.  137. 

'  Wei.ss:   (iuoleil  by  Cole,  H.  I.:  Osier's  .Modern  Medicine,  1>I07.  vol   iii.  p.  102. 


428  GONORRHEA    IN    WOMEN 

seen  in  the  Johns  Hopkins  Hospital,  only  7  were  females.  Kimball,' 
Haushalter,-  Heilman,^  Altland,^  Witherspoon,"  and  others'^  have  re- 
corded cases  in  infants  or  adults  who  were  suffering  from  gonorrheal 
ophthalmia. 

Lovett'  describes  the  following  types  of  arthritis:  (1)  Arthralgia 
without  definite  lesion  in  the  joints;  (2)  acute  serous  synovitis  with 
much  periarticular  swelling;  (3)  acute  fibrinous  or  plastic  synovitis 
with  slight  effusion;  (4)  chronic  serous  or  purulent  s,ynovitis,  and  (5) 
involvement  of  periarticular  structures,  such  as  bursse  and  tendon- 
sheaths.  These  forms  gradually  merge  into  one  another,  and  there  is 
no  sharp  dividing-line  between  them.  The  condition  may  be  acute  or 
subacute  from  the  onset,  or  one  condition  may  follow  the  other.  Sever** 
states  that  gonorrhea  is  followed  in  over  10  per  cent,  of  cases  by  joint 
involvement.  Clark''  places  the  proportion  at  2  per  cent.  Baer'" 
found  arthritis  in  from  1.5  per  cent,  to  3  per  cent,  of  all  cases.  In 
statistics  compiled  from  women  alone,  this  proportion  is  much  lower 
even  than  Baer's  figures. 

Symptoms. — These  usually  consist,  at  first,  of  pain  in  several 
joints,  which  in  a  few  days  becomes  localized  to  one  or  more  areas  and 
disappears  from  the  others.  The  pain  is  frequently  first  noticed  by  the 
patient  in  the  morning.  In  some  instances,  as  in  the  cases  recorded  by 
Adams,'!  the  onset  is  sudden,  but  more  frequently  premonitory  symp- 
toms arise.  Moderate  elevation  of  temperature,  occasionally  preceded 
by  a  chill,  and  the  accompanying  symptoms  of  fever,  are  usually  ob- 
served, and  are  always  present  in  the  acute  cases.  The  acute  stage 
commonly  lasts  three  or  four  weeks.  The  affected  joints  become  swol- 
len and  tender,  more  or  less  edema  is  present,  and  fluctuation  may  be 
marked.  The  pain,  which  varies  in  degree  in  different  cases,  is  aug- 
mented bj'  motion,  and  is  often  more  severe  at  night  than  during  the 
day.  The  fascia  and  tendons  of  the  joints  are  involved,  and  tender- 
ness of  adjacent  muscles  is  present.  Muscular  spasms  occur,  and  the 
joint  assumes  a  partially  flexed  position.  If  the  effusion  is  serous,  the 
local  condition  may  not  progress  beyond  the  stage  just  described. 

'Kimball:   Med.  Record,  November  14,  1903. 

-  Haushalter:  La  Sem.  Med.,  1895,  vol.  xv,  p.  .380. 

'  Heilman:   Med.  Record,  August  28,  1900. 

'  Altland:  Klin.  Monats.  f.  .\ugenheilk.,  April,  1902. 

^  Witherspoon,  J.  A.:  Jour.  Amer.  Med.  .\ssoe.,  February  2,  1907,  p.  377. 

«  Editorial,  Amer.  Med.,  April  2.5,  1903. 

'  Lovett,  R.  W.:  Keen's  Surgery,  1907,  p.  304. 

«  Sever,  J.  W.:  Boston  Med.  and  Surg.  Jour.,  May  16,  1912,  p.  727. 

'  Clark,  J.  B.:  Essays  on  Genito-Urinary  fiubjects.  New  York,  1912,  p.  04. 

'"  Baer,  A.  N.:  Amer.  Jour.  Dermat.,  190S,  vol.  xii,  p.  14. 

"  Adams:  Amer.  Jour.  Derinnt.,  1908,  vol.  xii,  p.  6. 


BONE    AND    JOINT    LESIONS    PRODt'CED    BY    GONORRHEA  429 

More  frequently,  however,  the  disease  advances,  and  the  joint  becomes 
extremely  swollen  and  exquisitely  tender.  Ankylosis,  generally  fib- 
rous, with  the  limb  in  a  more  or  less  abnormal  position,  and  atrophy 
of  the  involved  muscles,  may  occur.  Kienbock'  believes  that  neuritis 
is  a  frequent  accompaniment  of  arthritis.  Polyneuritis  is  probably 
the  cause  of  many  of  the  severe  muscular  atrophies  that  are  not  in- 
frequent in  this  disease.  Disuse  alone  can  hardly  be  considered  suf- 
ficient cause  to  explain  the  extent  of  many  of  these  atrophies.  A  rare 
sequela,  sometimes  observed  in  chronic  cases,  is  an  overstretching  of 
the  ligaments,  which  results  in  abnormal  mobility.  Anemia  is  gen- 
erallj'  present  in  chronic  cases.  If  suppuration  results,  the  skin  over 
the  affected  areas  becomes  reddened,  and  the  acute  symptoms,  both 
local  and  general,  increase  in  severity.  Rupture  of  the  synovial  mem- 
brane, with  the  formation  of  extra-articular  abscesses,  which  may  later 
burst  at  the  point  of  least  resistance,  are  not  infrequent  in  neglected 
cases.  Ware'-  has  described  the  history  of  a  case  complicated  l)y  the 
pre.sence  of  an  abscess  outside  the  joint. 

Death  occasionally  results  from  general  infection.  Jordan'*  has 
recorded  the  history  of  a  case  in  which  the  right  wrist  was  affected. 
The  nails  of  the  right  hand  were  dark  brown  and  deeply  furrowed  by  a 
transverse  groove,  this  condition  api)earing  shortly  after  the  arthritis 
and  tending  to  disapjiear  when  the  articular  symptoms  improved. 
Jordan  believed,  therefore,  that  the  condition  of  the  nails  was  a  mani- 
festation of  the  gonorrheal  arthritis.  This  was  not  proved.  Generally 
in  the  acute  form,  and  not  infrequently  in  the  chronic  stages,  gonococci 
can  be  demonstrated  in  the  joint  effusion.  They  may  be  found  free 
in  the  fluid  oi'  in  the  epithelium  or  pus-cells  of  the  effusion.  The  specific 
microorganism  can,  however,  be  recovered  nnich  more  constantly 
from  the  granulation  tissue  of  the  synovial  membrane  than  from  the 
fluid,  being  absent  from  the  latter  in  a  certain  proportion  of  cases.  It 
is  well  recognized  that  long-encapsulated  gonococci  tend  to  disappear, 
as  witness  the  sterile  contents  of  many  undoubted  gonorrheal  tubal 
lesions.  The  more  early,  therefore,  the  fluid  is  examined  during  the 
course  of  the  disease,  the  more  likely  are  gonococci  to  be  found. 

It  is  undoubtedly  true  that  purulent  collections  are  frecjuently  the 
result  of  a  mixed  infection,  but  the  view  formerly  held,  that  all  such 
cases  were  mixed  infections,  is  no  longer  tenable,  as  shown  by  the  l)ac- 
teriologic  studies  of  Young,'  who  demonstrated  conclusively  that  this 
condition  was  in  many  cases  due  to  the  gonococcus  in  pure  culture. 

'  Kicnl)6ik,  l{  :  Saimiil.  klin.  \iirl.,  Iiinorc  Mfil.,  No.  !I2,  lA>i|)/,in,  IIIIU,   p.  '>.i.i. 

■  Waro:   New  York  MimI.  .lour.,  .January  i:{.  H)05. 

'  .Ionian:  Kditorial  in  Amcr.  .lour.  DiTinal.,  !!)()!),  vol.  xiii,  p.  l.'ii). 

•  Vomit;.  H,  II.:  .lohii-^  Hopkins  Hosp.  Hcport.x,  vol.  ix,  p  (>77 


430  GONORRHEA   IN   WOMEN 

Diagnosis. — This  rests  largely  on  the  history  of  the  case  and  on  the 
detection  of  the  original  site  of  the  infection.  The  conditions  with 
which  gonorrheal  arthritis  are  most  likely  to  be  confused  are  rheuma- 
tism and  tuberculosis.  From  the  former  it  may  be  distinguished  by 
its  extreme  chronicity,  the  tendency  to  form  ankylosis,  the  smaller 
number  of  joints  involved,  especially  during  the  late  stage  of  the  dis- 
ease, and  the  fact  that  arthritis  may  attack  the  temporomaxillary,  the 
sternoclavicular,  or  even  the  sacro-iliac  joints,  areas  that  are  seldom 
if  ever  involved  in  rheumatism,  the  absence  of  lactic  acid  sweats,  the 
therapeutic  action  of  the  salicylates,  which  have  no  effect  upon  gon- 
orrheal arthritis,  and  the  greater  tendency  to  recur.  The  detection  of 
the  gonococcus  in  the  joint  effusion  and  the  discovery  of  the  original 
source  of  the  infection  confirm  the  diagnosis.  Gonorrheal  arthritis 
may  be  differentiated  from  tubercular  joint  lesions  by  the  history  of  the 
case,  the  presence  of  the  primary  lesion,  the  polyarticular  character  of 
the  disease,  especially  in  its  early  stages,  the  acuteness  of  symptoms,  the 
more  rapid  onset,  the  greater  severity  of  the  pain,  the  absence  of  epi- 
physeal involvement,  and  the  presence  of  gonococci  in  the  joint  effusion. 
Tubercular  joint  lesions  are  not  infrequently  secondary  to  tuberculosis 
in  other  parts  of  the  body.  In  doubtful  cases  the  serum  tests  may  be 
of  value.  In  tuberculosis  the  x-ray  will  disclose  the  osseous  nature  of 
the  disease.     It  is  unusual  for  gonorrhea  to  produce  true  bone  lesions. 

Prognosis. — The  prognosis  as  to  life  is  good,  but  as  to  complete 
functional  cure  it  should  be  guarded.  In  the  acute  form  suppuration 
and  partial  destruction  of  the  joint  are  frequent,  whereas  in  the  chronic 
type  ankylosis  from  partial  destruction  of  the  synovial  membrane  and 
the  formation  of  granulation  tissue,  in  which  fibrinous  organization 
ultimately  results,  is  common.  The  cases  in  which  the  effusion  is 
serous  and  is  limited  to  the  intra-articular  structures,  and  which  re- 
ceive prompt  treatment,  are  those  in  which  a  complete  functional  cure 
is  most  likely  to  be  secured.  So  long  as  any  swelling  remains  relapses 
may  occur.  Recurrences  are  frequent.  It  seems  probable  that  in 
some  cases  the  gonococcus  may  lie  dormant  in  the  joint  even  after 
apparent  cure.  Cole^  reports  the  history  of  an  interesting  case  of  this 
kind  in  which  no  subjective  symptoms  were  present  for  a  month,  but 
upon  the  death  of  the  patient  from  an  intercurrent  disease  gonococci 
were  recovered  from  the  joint  fluid.  The  history  of  a  previous  attack 
of  gonorrheal  arthritis  should  make  the  prognosis  more  guarded  so  far 
as  complete  recovery  is  concerned.  Ankylosis  is  somewhat  less  likely 
to  occur  in  children  than  in  adults. 

Some  writers  assert  that  gonorrheal  arthritis  is  responsiljle  for  a 
'  Cole,  R.  I.:  Osier's  Modern  Medicine,  Pliiladelphia,  1907,  vol.  iii,  p.  100, 


BONE    AND    JOINT    LESIONS    PRODUCED    BY    GONORRHEA  431 

definite  proportion  of  the  cases  of  arthritis  deformans.  This  assertion 
has  not  yet  been  definitely  proved.  In  McCrae's^  series  of  110  cases 
of  arthritis  deformans  only  14,  or  about  13  per  cent.,  gave  a  history  of 
having  had  gonorrhea.  As  early  as  1876  Bradford^  described  a  case  of 
ankylosis  of  the  vertebrae — the  so-called  spondylitis  deformans — which 
occurred  in  a  patient  who  had  suffered  from  repeated  attacks  of  gon- 
orrheal arthritis.  HeiligenthaP  refers  to  cases  the  histories  of  which 
have  been  reported  by  Raymond,  Marie,  Bier,  and  Rendu  and  Renault. 
In  many  of  the  cases  the  clinical  picture  closely  resembles  Pott's  dis- 
ease, but  the  condition  is,  however,  usually  more  painful,  especially 
during  the  acute  stage.     Kyphosis  is  often  present. 

Treatment. — This  depends  largely  upon  the  stage  of  the  disease,  the 
character  of  the  lesions  present,  and  the  amount  of  deformity.  In 
mild  acute  cases  immobilization,  either  in  splints  or  in  plaster-of-Paris, 
and  the  appUcation  of  cold  and  of  mercurial  or  ichthyol  ointment 
(50  per  cent.),  are  sufficient.  Zieler*  warns  against  too  long-continued 
immobilization,  owing  to  the  danger  of  resulting  ankylosis.  Young^ 
recommends  aspiration  if  the  effusion  is  marked,  and,  if  necessary, 
early  arthrotomy,  believing  that  by  such  treatment  the  disease  is 
checked  before  fibrous  tissue  has  had  time  to  form.  Some  authorities 
prefer  aspiration  and  washing  out  of  the  joint  with  2  per  cent,  phenol 
or  mercury  bichlorid  1  :  3000.  (lUyot*  reports  excellent  results  fol- 
lowing the  injection  of  the  latter  solution  in  13  cases.  To  prevent  the 
reaccumulation  of  the  fluid  the  joint  should  be  firmly  compres.sed  with 
a  flannel  bandage.  Hildebrand^  injects  5  per  cent,  tincture  of  iodin, 
and  reports  good  results  from  its  use.  For  a  knee  or  a  hip,  Hildebrand 
injects  5  grams.  This  is  followed  by  a  local  reaction,  increased  swell- 
ing, and  pain,  which,  however,  ([uickly  subside.  Good  functional 
results  are  usually  obtained.  Care  must  be  taken  not  to  use  too  large 
a  quantity  of  the  solution.  Early  arthrotomy  is  indicated  in  all  cases 
in  which  suppuration  occurs  in  the  joints.  As  much  as  possible  of  the 
diseased  tissue  should  be  removed,  and  the  joint  flushed  with  an  anti- 
septic solution.     Drainage  should  always  be  employed. 

During  the  chronic  stage  aspiration  and  irrigation  with  a  weak  anti- 
septic solution  should  be  resorted  to  if  much  effusion  is  present  or  if  the 
disease  is  persistent.     If  the  condition  tends  to  recur,  arthrotomy  may 

'  McCrao:  (^iiotcfl  l)y  Cole:  Osier's  Modern  Medieine,  1!)()7,  vol.  iii,  p.  109. 

•'  Hradford:   Boston  Med.  and  Surn-  .lour.,  1876,  vol.  ci,  p.  COS. 

'  IleiliRenthal:  Cent.  f.  d.  (irenzKeh.  iler  -Med.  u.  Cliir.,  1900,  vol.  ill,  p.  58. 

'  Zieler,  R.:   .Med.  Klinik,  Merlin,  February  11,  1912,  vol.  viii,  No.  0. 

'  Young:  Johns  Hopkins  llosp.  Keports,  vol.  ix,  p.  .532. 

"  (;uyot:  Th6.se  de  Paris,  190(). 

'  Hildebrand:   Berlin,  klin.  Woch<>nselir.,  July  M,  191  I. 


432  GONORRHEA    IN   WOMEN 

become  necessary.  Strapping,  compresses,  massage,  passive  motion, 
electricity,  and  hot  air  are  all  beneficial.  Bier,^  Hirsch,-  Treupel,^ 
Zieler,"*  and  Adams'^  strongly  recommend  the  use  of  passive  hyperemia. 
Hirsch*  has  reported  the  histories  of  36  cases  treated  by  this  method, 
with  satisfactory  results.  The  treatment  is  applied  by  means  of  a 
rubber  bandage  that  is  wound  about  the  limb,  well  above  the  affected 
joint.  The  bandage  should  be  just  tight  enough  to  produce  a  slight 
increase  in  the  edema,  the  extremity  becoming  warmer  and  of  a  slightly 
bluish  color.  The  veins  become  somewhat  prominent — the  so-called 
"heisse  Stauung,"  or  hot  damming.  In  no  case  should  the  constriction 
be  so  severe  as  seriously  to  interfere  with  the  circulation  and  produce 
coldness  in  the  limb — the  so-called  "kalte  Stauung,"  or  cold  damming. 
If  properly  apphed,  the  bandage  should  relieve  pain  and  not  increase  it. 
BieF  recommends  beginning  with  a  brief  treatment  of  about  one  hour, 
and  gradually  lengthening  the  periods  until  finallj^  the  compression 
remains  on  for  twelve  out  of  twenty-four  hours.  Zieler*  recommends 
that  the  treatment  be  applied  for  even  longer  periods — twenty  to 
twenty-two  hours  daily.  During  the  intervals  the  limb  should  be 
elevated  and  a  splint  applied  if  much  pain  is  present.  Braendle^ 
treated  17  cases  of  gonorrheal  arthritis  with  injections  of  fulmagin, 
a  substance  somewhat  similar  to  electrargol,  with  excellent  results. 
Ten  cubic  centimeters  were  injected  into  the  buttock  every  two  or 
three  days.  The  treatment  was  employed  in  conjunction  with  Bier's 
hyperemia. 

During  the  chronic  stage  Wilson'"  recommends  the  administration 
of  the  syrup  of  ferrous  iodid  in  30-drop  doses  three  times  a  day,  gradu- 
ally increasing  the  dosage  until  60  drops  are  taken.  Guiteras"  re- 
ports good  results  from  the  exhibition  of  20-minim  doses  of  oil  of  winter- 
green  every  four  hours.  In  certain  chronic  cases  potassium  iodid 
seems  to  exert  a  favorable  influence.  In  the  acute  cases  opium  or 
one  of  its  derivatives  may  be  required  to  relieve  the  pain,  but  should  be 
administered  guardedly,  for  fear  of  inducing  the  habit.  In  all  cases 
the  bowels  and  the  diet  should  be  regulated,  and  the  original  source 
of  the  infection  treated,  for  reinfection  is  possible.     Zieler'-  quotes 

'  Bier:  Hyperamie  a!s  Heilmittel,  fifth  ed.,  1907. 

^  Hirsch,  J.:  Berlin,  khn.  Wochenschr.,  1906. 

'  Treupel:  Miinch.  med.  Woch.,  1907,  No.  39. 

^  Zieler,  R.:  Med.  KHnik,  Berlin,  February  11,  1912,  vol.  viii,  Xo.  6. 

^  Adams,  E.:  .\mer.  Jour.  Dermat.,  1908,  vol.  xii,  p.  6.  "  Hirsch:   Loc.  cil. 

'  Bier:  Hyperamie  als  Heilmittel,  fifth  ed.,  1907. 

*  Zieler:  Med.  Kiinik,  Berhn,  February  11,  1912,  vol.  viii,  Xo.  6. 

»  Braendle,  E.:  Med.  KHnik,  1912. 

'"  Wilson,  J.  C:  Penn.  Med.  Jour.,  September,  1900. 

"  Guiteras,  R.:  New  York  Med.  Jour.,  March  24,  1904. 

"  Zieler,  R. :  Med.  Kiinik,  Berlin,  February  11,  1912,  vol.  viii,  Xo.  6. 


BONE    AND    JOINT    LESIONS    PRODUCED    BY    GONORRHEA  433 

Picker,  who  had  a  case  of  gonorrheal  arthritis  that  persisted  for  tliree 
years,  owing  to  an  unrecognized  reinfection.  Caution  should  alwaj'S 
be  observed  to  avoid  anything  likely  to  induce  exacerbations.  With 
the  subsidence  of  the  symptoms  the  patient  should  be  warned  of  the 
danger  of  recurrence,  and  prophylactic  measures  instituted. 

Gonorrheal  TENOSYNOvrris 

The  pathology  of  this  condition  is  practically  the  same  as  that  seen 
in  other  acute  infections.  It  may  arise  at  any  time  during  the  course 
of  a  gonorrhea,  but  occurs  most  frequently  during  the  chronic  stage. 
Usually  only  one  or  two  tendons  are  involved  simultaneously.  The 
condition  not  infrequently  occurs  in  conjunction  with  arthritis.  The 
inflammation  may  be  acute,  subacute,  or  chronic.  Pain,  swelling,  and 
edema  around  the  affected  tendon-sheaths  are  among  the  early  symp- 
toms. The  loss  of  function  and  the  inflammatory  changes  occurring 
in  a  young,  apparently  healthy  individual  are  suggestive  of  this  type 
of  infection.  The  history  of  gonorrhea,  and  finally  the  detection 
of  the  specific  microorganism  in  the  effusion,  confirm  the  diagnosis. 
Recurrences  are  frequent.  As  in  arthritis,  women  are  less  prone  to 
develop  this  complication  than  are  men  or  young  children.  Pregnant 
women  are  more  susceptible  than  their  non-gravid  sisters.  Numerous 
cases  have  been  recorded  in  which  the  gonococcus  has  been  recovered 
in  pure  cultures  from  the  effusion,  the  earliest  of  which  is  that  of 
Tollemer  and  Macaigne,^  which  was  followed  the  succeeding  year  by 
the  report  of  Jacobi  and  Goodman.- 

Treatment. — This  consists  of  rest  by  means  of  a  splint  and  the 
application  of  heat  or  cold.  Belladonna  and  mercury  ointment  seems 
to  be  of  value  in  some  cases.  When  the  symptoms  are  unusually 
severe,  and  the  pain,  heat,  and  swelling  are  marked,  small,  nniltiple 
incisions  or  punctures,  made  under  strict  aseptic  j^recautions,  give 
relief.  Fricdrich^  considers  this  of  great  value.  When  the  disease 
becomes  chronic,  massage,  countcrirritation,  hot  air,  and  liier's  method 
of  hyperemia  are  of  advantage.  Passive  motion,  to  prevent  disal)ility, 
adhesions,  and  deformities,  should  be  practised. 

Gonorrheal  OsTEOPERiosTrris 
It  is  only  rarely  in  gonorrheal  joint  lesions  that  the  bone  is  attacked. 
According  to  Hirtz,'  Fournier  was  the  first  definitely  to  establish  the 
clinical  existence  of  gonorrheal  periosteal  manifestations.     He  dis- 

'  Tollomcr  :iiul  MiicaiKne:  Kev.  do  M<5J.,  Paris,  November,  l.Si»H,  p.  '.lild. 

"  Jacobi  iind  (loodiimn:   Beit.  z.  klin.  Chir.,  1894,  vol.  xii,  p.  827. 

'  I'Viedrich:   Ilandb.  li.  praktisclieii  Chirurgie. 

<  Hirtz:  La  Presse  M(5d.,  1901),  vol.  ii,  p.  407. 

28 


434  GONORRHEA  IN   WOMEN 

tinguished  two  forms — periostitis  and  periostosis,  the  former  being  an 
inflammatory  reaction  in  the  periosteum,  and  the  latter  a  localized 
tumor  formation.  Periostitis  is  the  more  frequent,  and  usually  attacks 
the  tibia,  the  upper  portion  of  the  femur,  the  lower  part  of  the  humerus, 
and  the  extremities  of  the  metacarpal  or  metatarsal  bones.  Watts' 
and  Ducuing-  emphasize  the  epiphyseal  location  of  periostitis,  and 
state  that  it  is  frequently  associated  with  the  deforming  variety  of 
gonorrheal  arthritis.  In  Watts'  case  the  x-ray  showed  the  presence  of 
marked  thickening  of  the  diaphysis.  Durand  and  Nicolas^  believe 
that  only  in  extremely  rare  instances  do  gonorrheal  lesions  extend  from 
a  joint  to  an  adjoining  long  bone. 

Symptoms. — Pain  is  usually  the  most  pronounced  symptom,  and 
may  be  gradual  or  sudden  in  onset,  the  former  being  the  more  frequent. 
The  pain  is  generally  localized  to  the  affected  area,  although  soreness 
in  the  muscles  attached  to  the  diseased  structures  is  of  frequent  oc- 
currence. Constitutional  symptoms  are,  as  a  rule,  absent,  except  in 
the  acute  variety,  when  fever  and  its  accompanying  phenomena  may 
be  present.  Slight  edema  and  redness  over  the  affected  area  may  be 
present  in  the  early  stages  of  the  disease;  later  these  symptoms  may 
be  entirely  absent. 

Gonorrheal  exostosis  is  a  rare  condition.  Jaeger*  states  that, 
pathologically,  the  process  is  an  ossifying  periostitis.  The  tumors 
vary  considerably  in  size.  The  symptoms  are  not  always  proportion- 
ate to  the  size  of  the  spur.  Trauma  seems  to  be  a  predisposing  factor. 
Cases  have  been  described  by  Jacquet,''  Baer,^  Ulman,'  Jaeger,*  David- 
son,' Winthrop,"  Nobl,''  Davidson,'^  and  others.  About  20  cases  of 
gonorrheal  osteomyelitis  have  been  recorded.  The  os  calcis  is  the 
bone  most  frequently  attacked.  The  disease  is  frequently  bilateral. 
In  some  cases  the  only  symptom  is  pain  under  the  heel,  which  is 
frequently  ascribed  to  other  causes,  such  as  flat-foot,  tuberculosis,  etc. 
At  times  there  may  be  soreness  in  the  calf  muscles  or  over  the  entire 
plantar  surface  of  the  foot.     The  pain  is  increased  by  motion  or  pres- 

'  Watts,  S.  H.:  Jour.  Amcr.  Med.  Assoc,  August  19,  1911. 

^  Dueuing,  J.:  Province  Med.,  Paris,  1911,  vol.  xxii,  p.  122. 

*  Durand  and  Nicolas:  Lyon  M6d.,  1907,  vol.  cix,  p.  B93. 

■■  Jaeger:  Amer.  Jour.  Orthop.  Surg.,  January,  1908,  vol.  v,  No.  3. 

'  Jacquet:  Ann.  de  Dermat.  et  Syph.,  1892,  p.  681. 

'  Baer:  Surg.,  Gyn.,  and  Obst.,  1906,  vol.  ii,  p.  168. 

'  Ulman:  Wien.  med  Presse,  1900,  vol.  xii,  p.  222.5. 

'  Jaeger:  Amer.  Jour.  Orthop.  Surg.,  January,  1908. 

»  Davidson:   Med.  Record,  October  3,  1908. 

'"  Winthrop:  Jour.  Amer.  Med.  Assoc,  August  28,  1909. 

"  Nobl:  Zeit.  f.  Heilkunde,  1903,  vol.  xxiv,  p.  273. 

!•-  Davidson,  A.  J.:  Therap.  Gaz.,  April  l.i,  1911,  p.  243. 


I 


BONE  AND  JOINT  LESIONS  PRODUCED  BY  GONORRHEA     435 

sure,  and,  as  a  result,  the  patient  throws  the  weight  forward  on  the 
ball  of  the  foot,  and  while  walking  assumes  a  tip-toe  gait,  somewhat 
similar  to  that  of  a  man  walking  on  a  pebbly  beach  in  his  bare  feet. 
Pain  is  frequently  entirely  absent  except  when  pressure  is  applied  or 
the  patient  is  on  her  feet.  Increase  in  the  deep  leg  reflexes  and  even 
ankle-clonus  may  be  present.  The  condition  has  received  various 
names,  such  as  painful  heel,  painful  foot,  gonorrheal  heel,  and  talalgia. 
The  exostotic  tumors  freciuently  spring  from  the  tubercle  at  the  at- 
tachment of  the  flexor  brevis  digitorum,  just  in  front  of  the  point  of 
origin  of  the  plantar  fascia.  Later  other  osseous  growths  may  develop. 
In  Baer's^  case  the  plantar  surface  was  attacked.  The  diagnosis  is 
based  upon  the  history  of  the  case  and  on  the  local  findings.  The 
x-ray  will  reveal  the  osseous  nature  of  the  growth.  Exostoses  are  some- 
times present  at  the  side  of  and  between  the  vertebrae,  producing  the 
symptoms  of  osteo-arthritis  of  the  spine.  Two  such  cases  are  described 
by  Baer.- 

That  spur  formation  on  the  os  calcis  may  bo  produced  by  causes 
other  than  the  gonococcus  has  been  amply  proved.  Thus  Meisenbach* 
records  22  cases,  in  none  of  which  the  gonorrheal  origin  was  proved. 
Indeed,  this  author  emphasizes  the  rarity  of  the  gonorrheal  etiology  of 
the  condition. 

Treatment. — The  treatment  of  gonorrheal  periostitis  differs  in  no 
essential  respect  from  that  indicated  for  similar  lesions  produced  by 
other  types  of  infection,  except  that,  as  in  all  cases  of  metastatic  gon- 
orrhea, the  condition  that  was  the  original  source  of  the  infection  should 
receive  appropriate  treatment,  as  reinfection  is  possible.  Palliative 
treatment  of  gonorrheal  periostosis  is  of  little  avail.  The  outgrowths 
are  best  treated  by  operation,  which  consists  of  making  an  incision 
on  the  lateral  aspect  of  the  foot  and  removing  the  growths.  Recur- 
rence sometimes  follows  the  removal  of  the  tumor.  During  the  chronic 
.stage  some  cases  can  be  relieved  by  properly  fitted  foot-plates. 

Gonorrheal  Perichondritis  and  CHONDRms 
( (onorrhcal  periciioiuh-itis  and  clioiidritis  arc  extremely  rare  mani- 
festations of  gonorrhea.  Kimball'  reports  the  history  of  a  case  of  ab- 
scess of  the  larynx  between  the  mucous  membrane  and  the  thyroid 
cartilage.  The  patient  was  an  infant,  aii<l  gonococci  in  pure  culture 
were  recovered  from  the  pus  of  the  abscess  at  autop.sy.     FingcM-'  lias 

'  HiuT,  William  S.:  ,'^iiru  .  '  lyn  .  unit  Olwt.,  1<)()(),  vol.  ii,  p.  IC.S. 

■  liiicr,  William  S.:  ,Surn.,  (iyn.,  and  Obsl,,  1<)()(>,  vol.  ii,  p.  UiS. 

'  Mcis.nharli,  1{.  ().:  Amcr.  .louf.  Orlli.  Smu-.  I'"cl)ni:iry,  1912,  p.  457. 

'  Kimhall:   Med.  Hcconl,  1<.)():5,  vol.  Ixiv,  p.  Jill. 

'  FitiKcr:  (iuulcil  liy  ("ole:  Loc.  cit.,  ]^.  ll\. 


436  GONORRHEA    IN    WOMEN 

recorded  a  case  in  which,  during  an  attack  of  gonorrheal  arthritis, 
tenderness  and  swelling  developed  over  the  thyroid  cartilage.  The 
patient  recovered.  Finger,  Ghon  and  Schlagenhaufer'  were  the  first  to 
demonstrate  the  gonococci  in  pure  culture  from  a  case  of  perichondritis. 

GONORRHEAL  CARDIAC  LESIONS 
Endocarditis 

The  gonococcus  seems  to  possess  a  marked  predilection  for  the  en- 
docardium, and  when  the  heart  is  involved,  this  is  the  locality  most 
frequently  attacked.  As  early  as  1847  Eicord  called  attention  to  the 
frequent  association  of  endocarditis  with  urethritis,  and  since  then 
many  observers  have  studied  the  condition.  Thayer  and  Blumer- 
were  the  first  to  demonstrate  gonococci  in  pure  culture  in  the  circulat- 
ing blood  during  life,  and  to  recover  these  organisms  from  smears 
prepared  from  a  thrombus  on  the  heart  valve  at  autopsy.  Two  years 
later  Thayer  and  Lazear'  recorded  a  similar  case.  The  gonococcus 
may  produce  lesions  in  the  heart  in  pure  culture  or  a  mixed  infection 
may  be  present.  That  gonorrheal  endocarditis  is  by  no  means  in- 
frequent is  a  fact  now  well  recognized.  The  part  played  by  the  gono- 
coccus in  the  production  of  endocardial  lesions  is,  however,  probably 
often  overlooked,  on  account  of  the  well-known  difficulty  of  culti- 
vating this  microorganism  on  ordinary  media.  Norris**  found  this 
condition  once  in  a  series  of  60  cases  in  which  microorganisms  were 
detected  in  vegetations  or  in  blood  from  the  heart. 

In  well-marked  gonorrheal  septicemia  endocardial  involvement 
may  be  considered  the  rule,  rather  than  the  exception.  Dieulafoy^ 
states  that  this  condition  occurred  27  times  in  a  series  of  34  cases  of 
gonorrheal  septicemia  studied  by  him.  The  left  side  of  the  heart  is 
more  frequently  affected,  and  the  aortic  valves  are  more  often  involved 
than  the  mitral.  In  a  series  of  15  cases  collected  by  Thayer^  the 
valves  were  involved  in  the  following  order  of  frequency,  pure  cultures 
of  gonococci  being  obtained  from  each  case : 

Aortic 7  Tricuspid 1 

Mitral 2  Pulmonary 2 

Aortic  and  noitral 2  — 

—  3 

11 
'  Finger,  E.,  Ghon,  A.,  and  Schlagenhaufer,  F. :  Arch.  f.  Dermat.  u.  Syph.,  Vienna  and 
Leipzig,  1894,  vol.  xxviii,  3,  4  pi.,  p.  277. 

-  Thayer  and  Blumer;  Ai-ch.  de  med.  exper.  et  d'anat.,  path.,  Paris,  1895,  vol.  vii,  p. 
701. 

'  Thayer  and  Lazear:  Med.  Record,  New  York,  1S97,  vol.  lii,  p.  497. 
*  Norris,  G.  W.:  Studies  in  Cardiac  Pathology,  Pliiladelphia,  1911,  p.  26. 
s  Dieulafoy,  G.:   Internat.  Chnics,  1909,  vol.  iii,  nineteenth  series,  p.  64. 
5  Thayer:  Quoted  by  Cole:  Osier's  Modem  Medicine,  1907,  vol.  iii,  p.  97. 


GONORRHEAL    CARDIAC    LESIONS  437 

Thus,  in  73.3  per  cent,  of  cases  the  left  side  was  affected.  Both 
sides — all  four  valves — were  attacked  in  one  case.  Kiilbs^  reports 
the  results  found  in  49  cases  of  gonorrheal  endocarditis  as  follows: 

Aortic 28  Aortic  and  mitral 3 

Mitral 8  Mitral  and  tricuspid 1 

Pulmonic (5  Aortic,  mitral,  and  tricuspid ....  1 

Tricuspid I  All  valves 1 

Gurvich-  collected  110  cases,  the  tecords  of  77  of  which  left  Httle 
doubt  as  to  the  accuracy  of  the  diagnosis.  In  this  series  of  77  cases 
the  mitral  valve  was  involved  31  times;  the  aortic,  16  times;  and  both 
the  aortic  and  the  mitral,  13  times.  These  results  were  based  chiefly 
upon  clinical  findings.  In  1898  Sears'  reviewed  68  cases  of  gonorrheal 
endocarditis:  in  38  cases  the  mitral  valve  was  attacked,  in  12  the 
aortic,  and  in  2  the  pulmonic;  in  8  the  mitral  and  the  aortic  valves 
conjointly,  in  1  the  mitral  and  tricuspid,  and  in  1  the  mitral  and  pul- 
monic. In  4  the  lesion  was  not  definitely  defined.  In  Sear's  cases, 
as  in  those  of  Gurvich,  the  diagnosis  in  many  instances  was  based  upon 
the  cUnical  findings  only. 

The  patholog,v  of  the  mild  cases  is  not  definitely  known.  In  the 
cases  that  have  come  to  autopsy,-  ulcerative  and  proliferating  changes 
have  been  observed.  Deep  and  extensive  ulcerations  and  enormous 
polypoid  formations  are  not  unusual,  as  in  the  case  recorded  bj'' 
Marini.''  Occasionally  myocardial  abscesses  are  observed,  as  in  the 
case  reported  by  v.  Leyden.^  Perforation  of  a  valve  occasionally 
occurs,  just  as  in  similar  pathologic  conditions  produced  by  other 
organisms;  visceral  infarcts  are  not  infrequent,  but  do  not  by  any 
means  always  result  in  establishing  new  foci  of  infection. 

Like  other  forms  of  gonorrheal  septicemia,  gonorrheal  endocarditis 
occurs  more  freciuently  in  men  than  in  women.  Women  are  more 
susceptible  dm-iiig  i)rpgnancy  and  the  pucrperium  than  at  other  times. 
McDonald'''  and  Harris  and  Dabney^  have  reported  instances  of  this 
condition  occurring  during  the  pueri)erium.  Young  adults  are  most 
often  attacked,  although  the  aged  are  by  no  means  exempt.  Not  in- 
frequently children  are  victims  of  this  condition.  Kuil)s,*'  in  the  .series 
of  49  cases  previously  referred  to,  found  that   38  cases  occurred  in 

'  KiilUs:  Wicn.  klin.  Wochenschr.,  1907,  vol.  x.\,  p.  11. 

»  C;urvich:   Hu.s.sk.  Arch.  I'atol.  Klin.  Med.  i.  Bakt.,  1897,  vol.  iii,  p.  :«9. 

"  .Scars:   Ho.ston  City  Hosp.  Hcport.s,  1S98,  vol.  ix,  p.  201. 

*  Marini,  C:   II  MorgaRni,  1909,  vol.  li,  p.  17. 

» v.  Leyden:   Dout.  mctl.  Wochi-nschr.,  189:^,  p.  90f). 

'McDonald:   Annal.s  of  Surgery,  February,  1907. 

'  Harris  and  i:)al>ney:  Hull.  .lolin.s  Hopkins  Hosp.,  1901,  vol.  xii,  p.  68. 

"  Kiilbs:   Wion.  klin.  Wochenschr.,  1907,  vol.  xx,  p.  11. 


438  GONORRHEA    IN   "WOMEN 

men,  12  in  women,  and  1  in  a  female  child.  Of  Sears''  cases,  61  were 
men  and  7  were  women. 

The  etiology  is  similar  to  that  of  gonorrheal  septicemia.  Indeed, 
this,  like  other  secondary  forms  of  gonorrhea,  should  be  viewed  as  a 
local  manifestation  of  a  general  infection. 

Symptoms. — These  differ  in  no  essential  from  those  produced  by 
other  forms  of  endocarditis.  In  some  cases  the  manifestations  are 
mild,  whereas  in  others  grave  symptoms,  indicative  of  a  severe 
pyogenic  infection,  such  as  chills,  sweats,  intermittent  or  remittent 
fever,  marked  leukocytosis,  rapidly  progressive  anemia,  and  loss  of 
strength  and  flesh,  are  observed.  Septic  embolic  infarcts  may  de- 
velop, and  arthritis  is  a  frequent  complication.  Gurvich,-  in  a  series 
of  110  collected  cases,  found  arthritis  the  most  frequent  complication. 
Arthritis  was  present  in  48  of  the  68  cases  reviewed  by  Sears. ^ 

In  not  a  few  cases  the  joint  affection  precedes  the  cardiac  symptoms. 
Pericarditis,  peritonitis,  pleurisy,  and  other  systemic  manifestations 
of  the  infection  may  occur. 

Diagnosis. — This  depends  upon  the  finding  of  the  gonococcus  in  the 
heart  lesion.  The  occurrence  of  pyrexia  in  a  patient  the  incumbent  of 
an  uncured  gonorrhea  should  in  all  cases  lead  to  an  examination  of  the 
heart.     The  presence  of  an  arthritis  is  also  a  significant  symptom. 

Prognosis. — In  mild  cases  this  is  guardedly  favorable.  In  severe 
cases  the  prognosis  is  extremely  grave.    Recurrences  are  not  infrequent. 

Treatment.^-The  treatment  should  be  largely  symptomatic.  The 
patient  should  be  put  to  bed  and  cold  applied  to  the  precordium.  The 
diet  should  be  restricted,  the  bowels  regulated,  and  the  measures 
usually  adopted  for  the  treatment  of  endocarditis  instituted. 

Pericarditis 
The  pericardium  is  less  frequently  attacked  than  the  endocardium, 
although  Tyree^  found  this  condition  present  in  40  per  cent,  of  a  series 
of  fatal  cases.  From  this  it  will  be  seen  that  its  association  with  en- 
docarditis is  not  uncommon.  Councilman"'  has  recorded  the  history 
of  a  case  of  pericarditis  in  which  mj^ocardial  involvement  occurred. 
The  quantity  of  fluid  present  may  be  either  large  or  small.  Cole' 
relates  the  history  of  a  case  in  which  800  c.c.  of  exudate  was  seen. 
Serous,  hemorrhagic,  and  purulent  fluid  may  be  observed.     Quite  a 

'  Sears:  Loc.  cil. 

=  Gurvich:  Rassk.  Arch.  Patol.  KHn.  Med.  i.  Bakt.,  1897,  vol.  iii,  p.  329. 

»  Sears:  Boston  City  Hosp.  Reports,  1898,  vol.  ix,  p.  201. 

*  Tyree:  Quoted  by  Cole:  Osier's  Modern  Medicine,  1907,  vol.  iii. 

^  Councilman:   Amer.  Jour.  Med.  Sci.,  1903,  n.  s.,  vol.  cvi,  p.  277. 

'  Cole:  Csler's  Modern  Medicine,  1907,  vol.  iii. 


PHLEBITIS  439 

number  of  cases  of  gonorrheal  pericarditis  have  been  reported  in  the 
literature  during  the  last  ten  years.  Hoffman^  records  a  series  of 
these  cases. 

Myocarditis 

Myocarditis  alone  is  a  rare  manifestation  of  gonorrhea,  but  is 
frequently  jiresent  to  a  greater  or  less  extent  as  an  accompaniment  of 
endocarditis.  Marini-  reports  the  history  of  a  case  of  gonorrheal  sep- 
ticemia in  which  the  microorganisms  were  cultivated  from  the  myo- 
cardium, as  well  as  from  the  vegetations  on  the  heart-valves  and  on 
other  organs.  Councilman'  has  recorded  in  detail  the  history  of  a 
case  of  gonorrheal  myocarditis. 

Gonorrheal  AoRTms 
Koster^  cites  a  case  of  this  rare  condition  that  oecin-red  in  a  youth 
seventeen  years  of  age,  who,  after  a  virulent  attack  of  gonorrhea  com- 
plicated by  an  arthritis  and  endocarditis,  finally  developed  nephritis, 
pericarditis,  and  thrombi  in  the  veins  of  both  arms  and  died.  At 
autopsy  an  aortic  aneurysm  was  discovered.  The  aorta  was  inflamed, 
and  clots  adherent  to  the  wall  of  this  vessel  were  found  to  contain 
gonococci. 

PHLEBITIS 

Phlebitis  is  an  extremely  rare  com])lication  of  gonorrhea.  Zesas" 
has  reported  the  history  of  a  case  which  occurred  during  the  chronic 
stage  of  the  genital  lesion,  and  developed  after  the  patient  had  taken  a 
long  walk.  The  attack  was  acute  and  pain  was  a  marked  feature. 
The  saphenou.s  vein  was  the  vessel  involved.  The  case  was  treated 
by  elevation  of  the  limb  and  immobilization,  and  the  symjitoms  grad- 
vially  subsided. 

Phlebitis  is  rare  in  women.  S7  per  cent,  of  the  recorded  cases  having 
occurred  in  males,  and,  as  in  the  case  referred  t(j  by  Zesas,  it  often 
follows  prolonged  physical  exertion.  The  condition  most  frequently 
attacks  the  veins  of  the  lower  extremity,  but  may  affect  those  of  the 
pelvis  or  other  parts  of  the  body.  The  infiamniation  of  the  veins  may 
occur  during  either  the  acute  or  the  chronic  stage  of  th(>  i)riniary  in- 
fection, but  it  is  more  fre(iuent  during  the  former.  In  mild  cases  the 
attack  may  be  ushered  in  t)y  malaise  and  slight  fever,  i)ut  in  the  more 
severe  forms  hyperpyrexia  and  other  evidences  of  a  general  infection 

'  Hoffmun:  ("cnl.  d.  CrenzRpb.  d.  Med.  ii.  ("Iiir.,  l>)(i:i,  p.  M'2. 

■'  Miiriiii,  (;.:   II  .MoiKiiKni,  1900,  vol.  li.p.  17. 

'  C'oiiiiciliiian:   .Viiicr.  Jour.  Mcil.  Sc-i.,  lOOiJ,  n.  s.,  vol.  cvl,  p.  277. 

'  Ko.stcr,  M.:    MyKcia,  vol.  Ixxil,  (lolohorK's  Liikarcsallskaps  I'orlmiulliiiKar.  p.  27. 

■■  Zcsas:  .\irh.  K?-n.  (!<■  cliir.,  I'ails,  .luly  ^.j,  VMM.  No.  7. 


440  GONORRHEA    IN    WOMEN 

are  present,  and  are  often  associated  with  arthritis  or  endocarditis. 
Tenderness  along  the  course  of  the  affected  vein  usually  persists  for 
some  time  after  the  disappearance  of  the  swelling,  and,  as  a  result, 
there  may  be  impairment  of  function.  The  disease  usually  runs  its 
course  in  from  four  to  six  weeks,  but  in  obstinate  cases  it  may  persist 
much  longer. 

The  prognosis  is,  as  a  rule,  favorable.  Recurrences  are  not  infre- 
quent, and  may  occur  with  each  fresh  gonorrheal  infection.  Pul- 
monary embolism  rarely  results.  Heller^  has  collected  25  cases  from 
the  literature,  and  has  added  one  of  his  own;  16  of  these  cases 
recovered  completely.  Heller's  case  occurred  in  a  man  who  suffered 
from  an  acute  anterior  and  posterior  urethritis,  cystitis,  and  prosta- 
titis. When  the  symptoms  of  these  lesions  subsided  and  a  cure  had 
apparently  been  effected,  pain  appeared  in  the  calf  of  the  left  leg;  this 
soon  subsided,  and  three  days  later  an  indurated  area  3x4  cm.  could 
be  made  out.  The  skin  and  underlying  muscle  were  involved.  Heller 
at  first  believed  this  to  be  a  gonorrheal  myositis.  In  a  few  days  an 
elongated  swelling  appeared  in  the  right  groin,  accompanied  by  acute 
pain.  The  left  foot  was  swollen,  edematous,  and  a  hard  cord  could  be 
felt  extending  from  the  groin  along  the  course  of  the  external  saphenous 
vein.  HeUer  believes  that  there  was  also  a  phlebitis  of  the  pampini- 
form plexus.  In  one  case  mentioned  by  Heller,  gangrene,  which  re- 
quired amputation  of  the  limb,  occurred. 

Smith-  has  recorded  a  case  of  unusual  severity  that  occurred  during 
the  puerperium,  and  in  which  the  temperature  on  several  occasions 
reached  as  high  as  107°  F.  Recovery  occurred  after  eighty-three  days. 
Ghon  and  Schlagenhaufer^  have  recorded  the  history  of  a  case  in 
which  gangrene  of  the  foot  and  leg,  due  to  an  embolism  in  the  femoral 
artery,  occurred.  Tlie  condition  was  secondary  to  a  severe  endocardial 
lesion. 

In  the  majority  of  the  recorded  cases  conclusive  evidence  of  the 
gonococcal  origin  of  the  disease  is  lacking.  Arthritis  was  present  in 
16  of  the  cases  in  Heller's  series  and  in  a  number  of  those  recorded  by 
Zesas.'*  The  latter  author  states  that  if  relapses  occur  in  the  primary 
lesion  or  a  fresh  infection  is  acquired,  recurrence  is  likely  to  take 
place  in  the  vein  previously  attacked. 

Treatment. — This  does  not  differ  from  the  treatment  instituted  for 
ordinary  cases  of  phlebitis.     Complete  rest  and  elevation  and  immo- 

'  Heller:  Berlin,  klin.  Woch.,  1904,  vol.  xxiii,  p.  609. 

-  Smith,  J.  I.:  Cleveland  Med.  Jour.,  October,  1911,  p.  810. 

'  Ghon,  A.,  and  Schlagenhaufer,  F.:  Wien.  klin.  Wochenschr.,  1898,  vol.  xi,  p.  .380. 

*  Zesas:  Loc.  cil. 


THROMBOSIS  441 

bilization  of  the  affected  part  by  means  of  splints  and  bandages  are 
indicated. 

THROMBOSIS 
Thrombosis  the  result  of  gonococcal  infection  is  seldom  met  with, 
except  in  cases  of  frank  septicemia,  and  even  under  such  circumstances 
it  is  by  no  means  frequent.  In  cases  of  thrombophlebitis,  as  pre- 
viously stated,  the  internal  saphenous  vein  is  the  area  most  frequently 
attacked.  Cases  of  pulmonary  emboli  have  been  recorded,  but  are 
extremely  rare.  Gonococcal  thrombosis  usually  presents  symptoms 
and  pathologic  changes  similar  to  those  produced  by  other  organisms. 
As  a  rule,  they  are  only  moderately  severe,  although  the  course  is  often 
chronic.  Bender^  has  recently  reported  the  history  of  an  unusual  case 
in  which  a  thrombus  occurred  in  conjunction  with  an  abscess  of  Bar- 
tholin's gland. 

1  Bender:    Soc.  d'Obst.  et  de   Gvn.  de   P.iris,  April   22,  1912;    ;vlso   La  Gyndcologie, 
June,  1912,  p.  361. 


CHAPTER  XIX 

GONORRHEAL  SKIN  LESIONS.— GONORRHEA  OF  THE  LUNGS, 
PLEURA.  KIDNEY,  AND  NERVOUS  SYSTEM.— PAROTIDmS. 
—OTITIS.— SUPPURATIVE  MYOSITIS  AND  SUB- 
CUTANEOUS ABSCESS.— WOUND 
INFECTION 

GONORRHEAL  SKIN  LESIONS 

In  1872  Pedoux,  in  an  address  before  the  Societe  Medical  des 
Hopitaux,  mentioned  cutaneous  lesions  that  were  caused  by  gonorrhea. 
This  is,  perhaps,  the  earliest  reference  to  this  form  of  the  disease. 
Gonorrhea  of  the  skin,  although  a  rare  affection,  is  probably  more 
frequent  than  is  generally  supposed,  as  the  gonorrheal  etiology  is 
often  overlooked.  In  1909  Fiessinger^  was  able  to  collect  16  cases 
from  the  literature.  The  histories  of  cases  have  been  related  by 
Vidal,-  Jeanselme,'  Jacquet  and  Ghika,''  Chauffard,"  Robert,^  Lau- 
nois,''  Stanislawsky,*  Malherbe,^  Baermann,^"  Roth,"  Chauffard  and 
Froin,!-  De  Damany,'^  Hamm,'''  Wright,^=  Chauffard  and  Fiessinger," 
Rivet  and  Bricout,i'  Rosenthal,'^  Sequeira,"  Williams;-"  Chauffard,'-' 

'  Fiessinger,  N.:  ,Jour.  des  practieiens,  September  25,  1909. 

^  Vidal,  E.:  Annales  de  dermatologie  et  de  syphilographie,  1893,  p.  3. 

'  Jeanselme,  E.:  Ann.  de  dermat.  et  syph.,  Paris,  1895,  3.  S.,  vol.  vi,  p.  525. 

^  Jacquet  and  Ghika:  Soc.  M6d.  des  hop.  de  Paris,  January  22,  1897. 

'  Chauffard,  A. :  Soc.  Med.  des  hop.  de  Paris,  April  23,  1897;  also  Ikonographia  Derma- 
tologica,  1910,  vol.  v. 

«  Robert,  E. :  Thfese  de  Paris,  April  28,  1897. 

'  Launois,  P.  E.:  Soc.  M6d.  des  hop.  de  Paris,  July  21,  1899,  p.  736. 

'  Stanislawsky :  Monatsb.  uber  die  Gesamtleistungen  auf  dem  Gebiete  der  Erkrank- 
ungen  des  Harn-  und  Sexualapparates,  1900,  p.  643. 

'  Malherbe:  Gaz.  med.  de  Nantes,  1901,  No.  6. 

'"  Baermann,  G.:   Arch.  f.  Dermat.  u.  Syph.,  1904,  vol.  Ixix,  p.  363,  1  pi. 

"  Roth,  V. :  Munch,  med.  Woch.,  May  30,  1905,  p.  104. 

'-  Chauffard,  A.,  and  Froin:  Archives  de  M6d.  exper.  et  d'anatomie  pathologique,  Sep- 
tember, 1906,  No.  5. 

"  De  Damany:  Presse  M6d.,  1897,  No.  50,  p.  282. 

"  Hamm,  A.:  Beitr.  z.  Geb.  u.  Gyn.,  190S,  vol.  xiii.  No.  2. 

'°  Wright:  Jour.  Amer.  Med.  Assoc,  July  19,  1909,  p.  1996. 

'«  Chauffard,  A.,  and  Fiessinger,  N.:  Bull,  de  la  Soc.  de  Dermat.  et  Svph.,  May,  1909, 
No.  5,  p.  162. 

'"  Rivet,  L.,  and  Bricout,  C:  Bulletin  Medical,  Paris,  1909,  vol.  xxiii,  p.  851. 
»s  Rosenthal:  Arch.  f.  Dermat.  u.  Syph.,  March,  1910,  p.  105. 
"  Sequeira,  J.  H.:  Brit.  Jour.  Dermat.,  1910,  vol.  xxii,  p.  139. 
'0  Williams,  A.  W.:  Brit.  Jour.  Dermat.,  1910,  vol.  xxii,  p.  369. 
■-'  Chauffard,  A.:   Ikonographia  Derniatologica,  1910,  vol.  v. 

442 


GOXORRHEAL    SKIN    LESIONS  443 

Jacquet,'  Robin  and  Fiessinger,-  Rost-Kiel,''  Pugh^  (8  cases),  Simpson,^ 
Host,"  Orlipski,"  Hodara,**  Heerfordt,^  Arning  and  Meyer-Delius,'"  Ro- 
ark,"  Hodara,  Osman,  Izzet,  and  Chevket,'-  Haslund,"  Gougerot  and 
Saint-Marc,"  and  Swift. '= 

It  is  true  that  in  the  majority  of  these  cases  gonococci  have  not  been 
demonstrated  in  the  cutaneous  lesions.  That  this  organism  can  be 
the  cause  of  a  skin  eruption  there  is  little  doubt.  Baermann"^  and  Heer- 
fordt'"  have  directed  attention  to  the  fact  that  the  eruption  frequently 
waxes  and  wanes  with  the  infection,  an  exact  opposite  to  what  occurs 
in  arthritis.  It  may  be  that  in  some  instances  the  gonococci  are  pres- 
ent in  the  lesions  only  for  a  short  time  during  the  acute  stage,  and  dis- 
appear ciuickly,  or,  what  appears  more  likely,  that  these  conditions  are 
often  toxic  in  origin.  In  considering  the  latter  theory  it  must,  however, 
be  borne  in  mind  that  the  gonococcus  is  frequently  difficult  to  demon- 
strate in  lesions  known  to  be  produced  by  it,  and  that,  under  certain 
circumstances,  death  and  destruction  of  the  microorganisms  occur. 
From  the  biology  of  the  gonococcus  it  would  not  appear  that  the  skin, 
subject  as  it  is  to  frequent  changes  of  temperature  and  invested  chiefly 
by  squamous  ej)ithelium,  would  be  a  favorable  habitat  for  this  organ- 
ism. It  is  also  i)ossible  that  certain  of  the  skin  lesions  are  the  result  of 
a  mixed  infection.  .\s  predisposing  causes  toward  a  gonorrheal  skin 
eruption  C'hauffard  and  Fiessinger'*  suggest  confinement  to  bed  and 
restricted  motion,  profuse  perspiration,  with,  perhaps,  infi-cquent 
ablutions,  antl  the  wearing  of  rubber  stockings  or  the  prolonged  apj)li- 

'  .Jacquet,  L.:   Hull,  ot  Mrni.  Soc.  .Meii.  d.  hop.  <1.  Pari.'*,  1911,  vol.  xx>u,  p.  233. 

-Robin,  .\.,  and  Ficssingcr,  N.:  Bull,  do  lu  Soc.  Fian(;aise  de  Dermat.  et  de  Svpli., 
March,  1911,  vol.  xxii,  p.  97. 

'  Ro.st-Kifl,  G.:  Zoitsclu-.  f.  Urol.,  1910,  vol.  iv. 

*  Pugh,  W.  S.:  The  Military  Surgeon,  Juno,  1912,  p.  (jSO. 

'Simpson,  F.  E.:  .Jour.  .Vincr.  Med.  A.s.soc,  .\ugusl  24,  1912,  p.  (iOT. 

«  Ro.st:   Dermat.  Zeitschr.,  1911,  vol.  xviii,  p.  233. 

'  Orlip.ski:   Munch,  ined.  Woch.,  1902,  No.  40. 

'  Hodara,  M.:   Dermat.  Woohcn-schr.,  April  (i,  1912,  vol.  Iv,  p.  397. 

MIeerfordt:  Graefe'.s  .\rch.  f.  Ophth.,  vol.  Ixxvii,  No.  1;  also  Arch.  f.  Dctiniit.  u. 
Syph.,  .May,  1911,  p.  361. 

'"  .\rning,  10.,  and  Meyer-Delius:  .\r<'li.  f.  Dermat.  u.  Syph.,  N'ienna  and  Leipzig, 
191 1,  vol.  cviii,  p.  3. 

"  Roark,  B.  H.:  Jour.  .■Xmer.  Med.  .\.s.soc.,  Novemher  23,  1912,  p.  2039. 

"  Hodara,  Osman,  Izzet,  and  Chevket:  Gaz.  M<:-d,  <rOrieiit.,  June,  1911,  p.  143. 

'■' Hiwiund,  O.:    Ugeskrift  f.  Liieger,  Copenhagen,  Fehruary  13,  1913. 

'*  Gougerot  and  Saint-Marc:   .\nn.  de.s  nial.  vi'mi.,  1912,  No.  1,  p.  sis. 

"Swift,  H.:  Aastral  .Med.  Gaz.,  Xovemher  23,  1912. 

'"  Baerinaiin,  G.:  .\reh.  f.  Dermat.  ii.  Syph.,  1904,  vol.  xix,  p.  3li3. 

"  Heerfonll:  Graefe'.s  .\rch.  f.  Ophthal.,  vol.  I.\xvii,  No.  1;  al.so  .\rch.  f.  Dermal,  u. 
Syph..  .May,  1911,  p.  3(il. 

"  rh;iulTard  and  Fie.ssinger:  Bull.de  la  Soc.  Fran,  de  Derm.at.el  dc  Syph.,  May, 
1909,  p.  11)2;   al.io  Ikonogijiphia  Dermatologica,  191(1. 


444  GONORRHEA   IN   WOMEN 

cation  of  a  Bier's  band.  These  factors  certainly  favor  the  maceration 
of  the  epidermis  and  the  accumulation  of  scales.  These  authors  per- 
formed an  interesting  series  of  experiments.  They  found  that  when 
the  skin  was  abraded  and  a  serum  obtained  from  beneath  a  keratotic 
crust  rubbed  in,  and  the  area  covered  with  a  watch-crystal,  they  were 
able  to  reproduce  the  eruption  in  a  keratotic  patient.  Similar  lesions 
were  not  caused,  however,  in  healthy  subjects. 

Skin  lesions  may  be  produced  by  gonococci  in  pure  culture  or  in 
combination  with  other  micro5rganisms.  Gonorrheal  lesions  of  the 
skin  must  be  regarded,  in  the  large  majority  of  cases,  as  local  manifes- 
tations of  a  general  infection,  and,  in  fact,  it  is  only  rarely  that  this 
condition  is  not  associated  with  other  systemic  affections,  such  as 
arthritis,  tenosynovitis,  or  endocarditis.  Skin  lesions  are  most  fre- 
quent in  severe  gonorrheal  infections.  Many  of  the  recorded  cases 
have  been  in  patients  suffering  from  frank  gonorrheal  septicemia  or 
pyemia.  The  cutaneous  manifestations  may  occur  at  any  time  dur- 
ing the  course  of  the  initial  lesion,  but  are  probably  more  frequent 
during  the  second  month  of  the  disease,  and  are  more  common  during 
second  or  subsequent  attacks  than  during  the  initial  infection.  Like 
other  systemic  manifestations  of  gonorrhea,  skin  lesions  are  more 
frequent  in  men  than  in  women,  and  during  childhood,  pregnancy,  and 
the  puerperium,  than  in  non-gravid  females. 

Buschke^  has  exhaustively  studied  gonorrhea  of  the  skin,  and  di- 
vides the  lesions  into  four  varieties : 

Simple  Erythema. — This  is  usually  manifested  by  small,  red,  papu- 
lar elevations,  which  frequently  occur  on  the  trunk,  arms,  or  thighs, 
and  in  some  cases  closely  resemble  the  rose  spots  of  typhoid.  This 
eruption  often  occurs  during  the  course  of  a  gonorrheal  septicemia,  and 
has  been  noted  by  Dieulafoy,^  Thayer  and  Silvestrini,'  Irons,*  Pugh,^ 
and  others.  A  moderate  degree  of  erythema  is  not  infrequent  about 
the  external  genitalia  of  women  suffering  from  gonorrhea  of  the  lower 
genital  tract.     It  is  probably  caused  by  the  toxins  in  the  discharge. 

Urticaria  or  Erythema  Nodosum. — The  lesions  consist  of  firm, 
rounded  or  oval,  deeply  infiltrated  nodes,  which  occur  in  the  subcu- 
taneous tissue  and  often  resemble  the  ordinary  variety  of  erythema 
nodosa.  Arthritis,  endocarditis,  or  other  manifestations  of  a  gon- 
orrheal septicemia  are  usually  present. 

'  Buschke,  A.:  Arch.  f.  Dermat.  u.  Syph.,  Vienna  and  Leipzig,  1899,  vol.  xlviii,  p.  181. 
=  Dieulafoy,  G.:  Internat.  CHnics,  1909,  vol.  iii,  nineteenth  series,  p.  64. 
'  Thayer  and  Silve.strini :    Quoted  by  Dieulafoy:    Internat.  Clinics,  1909,  vol.  iii,  nine- 
teenth series. 

*  Irons:  Abst.  Amer.  Jour.  Urol.,  1910,  vol.  \'i,  p.  264. 
5  Pugh:  The  Military  Surgeon,  June,  1912,  p.  686. 


GONORRHEAL    SKIN    LESIONS  445 

Bullous  or  Hemorrhagic  Eruption. — These  lesions  are  of  rare  oc- 
currence, and  are  probably  embolic  in  origin.  They  are  usually  pres- 
ent only  in  severe  cases  of  septicemia.  Paulsen^  records  the  history  of 
a  case  of  this  variety  occurring  in  a  child.  The  eruption  was  chiefly  on 
the  face  and  on  the  inner  side  of  the  thighs.  Gonococci  were  demon- 
strated in  smear  preparations. 

Hyperkeratosis. — Keratodermie  blennorrhagique  was  first  de- 
scribed bj-  Mdal-  in  1893.  In  1904  Baermann^  reported  the  history  of 
a  case  of  this  rare  condition.  In  all  recorded  cases  of  this  variety  of 
gonorrheal  skin  lesions  complications,  such  as  arthritis  or  endocarditis, 
have  occurred.  The  eruption  occurs  on  the  plantar  surfaces  of  the 
feet,  on  the  palms  of  the  hands,  or  about  the  nails,  and  occasionally  on 
other  parts  of  the  extremities  or  trunk.  It  is  often  bilateral.  Many 
of  the  French  writers  believe  that  the  pathologj'  of  this  condition  is  due 
to  a  trophoneurosis;  in  this  Buschke^  does  not  concur.  He  does  not 
believe  that  the  condition  is  a  true  keratosis,  but  suggests  the  term 
"dermatitis  papillaris  parakeratotica."  Chauffard  and  Fiessinger^ 
have  also  abandoned  the  trophic  theory  of  the  eruption.  De  Damany* 
suggests  the  term  "hyperkeratosis  dermopapillitis." 

The  pathology  of  a  case  of  this  condition  is  described  by  TurnbalF 
as  follows:  The  node  is  covered  by  a  thick,  horny  capsule.  The  inter- 
papillary  processes  beneath  this  are  much  lengthened.  The  papillae  are 
very  edematous  and  much  infiltrated.  In  the  subjacent  derma  there  is 
no  edema,  but  a  little  infiltration,  especially  around  the  vessels.  The 
infiltration  in  the  derma  consists  of  lymphocj'tes  with  a  large  number 
of  mononuclear  and  binuclear  plasma-cells  (Unna-Pappenheim  stain). 
There  are  a  few  neutrophile  polymorphonuclear  leukocytes  in  the 
upper  part  of  the  papillaj  and  many  in  the  capillaries.  Only  one  or  two 
eosinophiles  were  found.  No  mast-cells  are  seen.  In  the  epidermis, 
the  lower  part  of  the  Malpighian  laj-er  shows  clear,  prickle  borders; 
karyokinctic  figures  are  present  in  the  basal  layer.  Varying  numbers  of 
neutrophile  leukocytes  are  seen  in  these  layers.  A  stratvmi  granulosuni 
is  recognizable  only  in  places.  At  this  level  there  are  verj'  large  mun- 
bersof  neutrophile  polymorphonuclear  leukocytes  in  masses,  occujiying 
rounded  spaces  formed  l>y  the  degeneration  of  epithelial  cells.     The 

'  P.-iuLsen:  Munch,  mod.  Woch.,  1900,  vol.  xlvii,  p.  120'.). 
'  Viilal:  Soc.  (le  Derniiitologic,  January  12,  189:5. 
'  Haorniann:  .Vrch.  f.  Dcrniat.  ii.  Sypli.,  1904,  vol.  Ixix,  p.  W^i. 

'  IJii.sclikf,  .\.:  .\rch.  f.  Dormat.  u.  Sypli.,  Vienna  and  Leipzig,  1899,  vol.  xlviil,  p.  181. 
'  C:iiaiilTard  ami  Fios.siiigor:   Hull,  dc  la  Soc.  Fran,  de  Derniat.  ct  Syph.,  May,  1909,  p. 
102;  al.so  Ikoiiographia  Dcrtnutologia,  1910. 

«  De  Damaiiy:  La  Pie.sse  MM.,  1897,  No.  .'jO,  p.  282. 

'  .Snuioira,  .1.  II..  anil  Tuinliall:   Mrit.  .lour.  Derniat.,  1910,  vol.  xxii,  p.  139. 


446  GONORRHEA   IN   WOMEN 

superficial  horny  layers  contain  many  flattened  nuclei  and  collections 
of  neutrophile  leukocytes  lying  in  strands  between  the  horny  layers;  A 
superficial  layer  of  horny  substance  without  nuclei  is  present  in  part 
of  some  of  the  sections.  Herzog,^  Chauffard  and  Fiessinger,-  Chauf- 
fard  and  Froin,^  Chauffard,^  and  Baermann^  have  also  described  this 
condition. 

Macroscopically,  the  eruption  appears  in  the  form  of  hard  masses, 
studded  with  transparent  conic  tips.  The  lesions  maj^  appear  as 
horns  or  conic  projections,  or  as  large,  irregular,  indurated  patches 
composed  of  hornified  epidermis.  It  is  generally  symmetric,  both 
hands  or  both  feet  being  involved.  Gonorrheal  keratoid  eruptions 
are  not  necessarily  confined  to  the  palms  of  the  hands  or  the  soles  of  the 
feet,  but  are  generally  found  in  these  localities.  The  masses  are  usually 
circular,  dome-like  elevations,  the  bases  of  which  are  at  first  reddened. 
Later  the  base  becomes  more  or  less  devoid  of  reaction.  The  eruption 
usually  lasts  for  from  one  to  three  months,  when  the  plaques  drop  off, 
leaving  a  dark,  dirty,  reddish-brown  macule.  If  the  upper  part  of  the 
cone  is  prematurely  detached,  a  moist,  red,  non-bleeding  area  will  be 
found.  On  the  under  surface  of  the  peeled  mass  is  a  slimy,  grayish- 
white,  putty-like  material,  composed  of  softened  horny  cells.  Des- 
quamation of  the  diffuse  keratosis  occurs  simultaneously  with  the 
dropping  off  of  placjues. 

The  eruption  may  be  diffuse  or  confluent,  and  if  arthritis  is  present, 
is  frequently  more  severe  on  the  extremity  attacked  by  the  articular 
inflammation.  In  the  cases  described  by  Roark,*  Simpson,'  and  Arning 
and  Meyer-Delius*  lesions  were  present  that  resembled  the  pustules 
of  small-pox.     No  scars  are  left  by  the  eruption. 

The  disease  usually  has  a  moderately  rapid  onset.  The  subjective 
symptoms  do  not  differ  from  those  produced  by  hyperkeratosis  of  the 
ordinary  variety.  Not  infrequently  grave  debility  and  cachexia  are 
present,  but  these  result  from  the  general  infection  and  not  from  the 
skin  lesions.  The  condition  is  chronic,  and  in  some  of  the  cases  re- 
corded by  De  Damany'-'  recurrences  occurred  with  fresh  attacks  of 

'  Hcrzog,  M,:  Jour.  Amer.  Med.  Assoc,  August  12,  1912. 

=  Chiiuffard  and  Fiessinger:  Bull,  de  la  Soc.  Fran,  de  Dermat.  et  Syph.,  May,  1009, 
p.  1()2;   also  Ikonograpliia  Dermatologia,  1910. 

'  Chauffard  and  Froin:   Arch,  de  m^d.  expgr.  et  d'anat.  path.,  September,  1906,  No.  3. 
'  Chauffard:  Soc.  m6d.  hop.  de  Paris,  April  23,  1897. 

*  Baermann:  ,\rch.  f.  Dermat.  u.  Syph.,  1904,  vol.  Ixxix,  p.  363. 
«  Roark,  B.  H.:  Jour.  Amer.  Med.  Assoc,  November  23,  1912. 

'  Simpson,  F.  E. :  Jour.  Amer.  Med.  Assoc,  August  24,  1912. 

*  Arning,  E.,  and  Meyer-Delius:  Arch.  f.  Dermat.  u.  Syph.,  Vienna  and  Leipzig,  1911, 
vol.  cviii,  p.  3,  3  pi. 

»  Do  D.amany:  La  Pre.sse  M6d.,  1897,  No.  50,  p.  282. 


Flo.  38. K^RATODKHMIK  BLKNNOHKHAGiyUK. 

lowinie  thickening  of  squHmou.H  epithelium  and  infla 
(Cu«e  of  Dr.  F.  E.  Simpson.) 


GONORRHEAL    SKIN    LESIONS  447 

gonorrhea.  In  a  case  reported  by  Jacquet  and  Ghika'  the  patient  had 
.six  attacks  of  gonorrhea.  In  the  first  there  was  lu'ethritis  only;  in  the 
second  and  third,  urethritis  and  arthritis;  in  the  fourth,  fifth,  and  sixth, 
urethritis,  arthritis,  and  keratodermia.  Fiessinger-  considers  macera- 
tion of  the  skin  l)y  retained  sweat  to  be  a  predisposing  cause  of  the  con- 
dition. An  excellent  resume  of  the  literature  pertaining  to  this  rare 
condition  may  be  found  in  Simpson's^  paper,  together  with  abstracts  of 
cases  reported  by  the  following  authors :  Vidal,''  Jeanselme,^  Jacquet  and 
Ghika,^  Chauffard,'  Robert**  (2  cases),  Launois,"  Stanislaw-sky,'"  Mal- 
herbe,"  Baermann'-  (2  cases),  Roth,^'  Chauffard  and  Froin"  (2  cases), 
Chauffard  and  Fiessinger^^  (2  cases).  Rivet  and  Bricout,^*  Williams,'' 
Little  and  Douglas,'*  and  Simpson.'^  Of  these  21  cases,  gonorrheal  ar- 
thritis was  present  in  all  but  2.  Other  manifestations  of  a  general  infec- 
tion were  present  in  nearly  all  the  cases.  Ophthalmia,  iritis,  cachexia, 
fever,  or  general  weakness  was  observed  in  many.  The  majority  of 
the  patients  were  in  the  prime  of  life.  In  one  of  Robert's-"  cases  the 
l)atient  was  a  child  four  years  of  age.  This  is  the  youngest  recorded 
instance  of  this  condition.  In  14  of  the  cases  the  eruption  was  more 
or  less  synunetric.  Four  of  the  patients  had  suffered  from  previous 
attacks  of  the  disease. 

The  number  of  attacks  of  gonorrhea  does  not  seem  to  be  of  great 
importance,  as  in  some  of  the  cases  the  eruption  appeared  during  the 
first  attack,  whereas  in  others  it  appeared  in  the  second,  third,  or 
fourth  attack.     The  lesions  varied  from  a  few  millimeters  to  3  or  4  cm. 

'  Jacquet  and  (Jhika:   Bull,  ot  M^-m.  Soc.  Mt'-d.  de.-i  Hop.  de  Pari.s,  January  22,  1897. 
'Fiessinger,  X.:    Bull,  de  la  Soc.  Fran,  dc  Derniat.  ot  do  Syph.,  March,   1911,  vol. 
xxii,  p.  97. 

'Simpson,  F.  K. :  Jour.  .Vmor.  Med.  .V.ssoc,  .Vugust  24,  1912. 

*  Vidal,  K.:  .\nn.  do  Dormat.  ot  de  Syph.,  1893.  p.  3. 

'  .leansehne:   Ann.  de  dormat.  ot  syph.,  Paris,  189,i,  3  S.,  vol.  vi,  p.  .52,5. 

•  Jacquet  and  ( ihika:  Bull,  et  M<^m.  Soe.  Med.  des  Hop.  de  Paris,  January  22,  1897,  p.  93. 
'  Chauffard:  ll>i,l.,  .\pril  23,  1897.  »  Robert:  Th^se  de  Paris,  .\pril  28,  1897. 
»  Launois,  P.  K.:  Soc.  niftl.  des  h6p.  do  Paris,  July  21,  1S99,  p.  736. 

'"  Staiiitilawsky:  "I'ebor  einen  Fall  von  (joiioii-jioi.sclii'r  Frethritis  niit  .\ffektion  der 
(lolenko,  .syniiiiclrisclioni,  liornarti(ten  .Xussclilag.  und  .Ausrallcn  der  XiiKol."  Monatsbericht 
iibor  die  (iosaintleistuiigcti  :i.  d.  ('>cbii'le  der  l':rkraMkuiii;<'ii  des  llarii-  uml  Soxualap|iarates, 
19(l<),  p.  043. 

"  .Malherbe:   Uaz.  nie  1.  de  Xanles,  191)1,  No.  ti. 

"  Baerniann:  .\rch.  f.  Dormat.  u.  .Syph.,  1904,  vol.  Ixix,  p.  303. 

"  Rotli,  v.:   Munch,  mod.  Wocli.,  May  30,  190.5,  p.  104. 

"  ChaufTard  and  Froin:  .\rch.  do  nio<l.  expor.  ot  d'anal.  path.,  September,  1906,  Xo.  3. 

"ChaulTard,  .\.,  and  Fiessinger,  X.:  Hull.de  la  Soe.  Fran,  do  Dormat.  et  Syph.,  May, 
l''09,  Xo.  .5,  p.  102;  also  Ikr)nographia  Dermatologiea,  1910. 

'«  Kivet  and  Bricout :   Bull.  me<l.,  1909,  vol.  xxiii,  p.  8.51. 

'"Williams.  A.  \V.:  Proc.  Hoy.  .Soc.  Med.,  London,  1911,  vol.  iv,  part  1,  p.  12;  also 
Brit.  Jour.  Dirniat.,  1910,  vol.  xxii,  pp.  361  and  30;). 

"  Little,  K.  C.  (!.,  and  Douglas,  S.  H.:   llnil.,  1911,  vol.  v.  part  I,  p.  8. 

"  Sirn[)son,  F.  K.:  Jour.  .\mor.  Med.  .A.s.soe.,  .Vugust  21,  1912. 

•"  Hoberl :  Th&se  de  Pari.s,  April  2X,  1897. 


448  GONORRHEA    IN    WOMEN 

or  more  in  diameter.  Thickening  of  the  skin  on  the  pahns  of  the  hands 
and  soles  of  the  feet  was  present  in  many.  The  nails  in  many  cases 
were  also  thickened. 

Hodara^  has  reported  the  history  of  an  interesting  case  of  eruption 
due  to  gonococceniia.  The  cutaneous  manifestation  appeared  as  a 
livid  eruption,  somewhat  resembling  erythema  multiforme,  upon  the 
thorax,  abdomen,  and  face,  with  a  few  spots  on  the  extremities.  Within 
a  day  or  two  the  eruption  became  generalized,  and  several  large 
vesicles  developed,  containing  sanguinopurulent  fluid.  Later  the 
eruption  increased  and  the  contents  of  the  vesicles  became  fetid. 
Meanwhile  the  temperature  varied  from  100°  to  103°  F.  By  the 
eleventh  day  the  acute  appearance  of  the  eruption  had  disappeared, 
and  desquamation  had  begun.  Gonococci  were  cultivated  from  the 
blood.  Histologically,  the  skin  lesions  presented  the  picture  of  a 
suppurative  inflammation  of  the  papillary  body  and  epidermis. 

Grosz-  has  reported  a  case  of  gonorrheal  folliculitis  and  perifollicu- 
litis. A  case  of  folliculitis  has  also  been  recorded  by  Wright.^  Chor- 
naguboffna^  has  also  studied  this  condition.  An  urticaria-like  erup- 
tion, attributed  to  gonorrhea,  has  been  described  by  Orlipski,'^  and 
Balzer  and  Lacour'^  have  reported  a  case  of  purpura  probably  due  to 
gonorrhea. 

Ulcers. — Gonorrheal  ulcers  occurring  in  the  skin  are  of  unusual 
occurrence.  Mestschersky'  reports  the  history  of  a  case  of  multiple 
serpiginous  ulcers  that  were  due  to  gonorrhea.  The  lesions  occurred  in 
the  external  gehitalia,  and  were  of  a  severe  chronic  grade.  The  condi- 
tion was  caused  by  a  mixed  infection,  staphylococci  and  gonococci  being 
present.  An  interesting  feature  of  this  case  was  that  the  gonococci 
were  demonstrable  only  after  the  application  of  a  strong  solution  of 
protargol.  Mestschersky  believes  that  the  ulcers  were  the  result  of  a 
lymphatic  infection.  The  neighboring  lymphatic  glands  were  also 
involved.  Rendu  and  Halle**  relate  the  history  of  a  case  in  which  gono- 
cocci in  pure  culture  were  demonstrated  in  the  endometrium  removed 
by  curetage  and  from  a  chronic  ulcer  at  the  elbow.  Gonorrheal  endo- 
carditis and  other  evidences  of  a  septicemia  were  present.     Horwitz 

1  Hodara,  H.:  Dermat.  Woch.,  April  6,  1912. 

'  Grosz,  S.:  Handb.  d.  Geschlechtskr.,  Leipzig  u.  Vienna,  1910,  vol.  i,  p.  684. 
^Wright:  Abstract  in  Progressive  Medicine,  September,  1911,  the  reference  to  which 
is  erroneous. 

-•  Chornaguboffna:  Russk.  J.  Kazhn.  i  Yen.  Boltezn.  Mosk.,  1911,  vol.  xxii,  1  pi. 

'Orlipski:  Miinch.  med.  Woch.,  October  7,  1902. 

«  Balzer  and  Lecour:  Annal.  de  Dermatologie,  August,  1894. 

'  Mestschersky,  G.:  Annal.  des  maladies  veneriennes,  December,  1910,  vol.  v,  No.  12. 

8  Rendu  and  Halle:  Bull,  et  M6m.  Soo.  Med.  de  Hop.  de  Paris,  1897,  vol.  xiv,  p.  1325. 


GONORRHEA    OF   THE    LUNGS  449 

and  Lang'  found  the  gonococcus  in  an  ulcer  situated  upon  the  back  of 
the  hand. 

Diagnosis. — The  diagnosis  of  gonorrhea  of  the  skin  depends  upon  the 
demonstration  of  the  specific  microorganism  in  the  cutaneous  lesion. 
Especial  care  must  be  exercised  to  exclude  all  drug  rashes  that  may 
result  from  treatment  of  a  simple  genital  gonorrhea.  The  lesions  must 
also  be  differentiated  from  the  various  syphilids.  Cutaneous  lesions  oc- 
curring during  the  course  of  a  gonorrheal  septicemia  or  in  conjunction 
with  a  gonorrheal  arthritis  are  strongly  suggestive  of  this  type  of  in- 
fection. 

Paulsen-  has  called  attention  to  the  fact  that  various  cutaneous 
lesions  may  result  from  inoculation  by  the  gonococcus  during  birth, 
and  has  described  several  such  cases  in  infants. 

Treatment. — This  naturally  varies  according  to  the  stage  and  se- 
verit}'  of  the  pathologic  condition  present.  Simple  erythemata  are, 
as  a  rule,  transient  and  do  not  reciuire  treatment.  In  the  more  severe 
lesions  cleanliness  and  the  application  of  antiseptics,  especially  the 
silver  salts,  are  of  benefit.  The  .r-ray,  which  has  been  employed  with 
advantage  in  the  treatment  of  ordinary  venereal  warts,  has  been  sug- 
gested for  the  treatment  of  the  .keratoid  variety  of  gonorrhea  of  the 
skin,  which,  from  a  histologic  basis,  is  somewhat  similar  to  condylo-. 
mata  acuminata.  Constitutional  treatment  is  indicated  if  a  septicemia 
is  present.  Tonics  and  improved  hygiene  are  necessary  in  debilitated 
l)atients. 

GONORRHEA  OF  THE  LUNGS 
During  the  course  of  a  gonorrheal  septicemia  the  lungs  arc  some- 
times attacked.  Dieulafoy'  records  the  history  of  a  case,  the  lesion 
being  a  double  bronchopneumonia,  which  for  a  week  placed  the  pa- 
tient's life  in  danger.  Bressel,''  Thayer  and  Lazear,-'  and  Wynn* 
also  record  cases  of  this  condition.  Thayer  and  Blumer^  relate  the 
history  of  a  case  in  which  there  were  several  patches  of  bronchopneu- 
monia with  hemorrhagic  infarcts.  The  symptoms  of  gonorrheal 
pneumonia  do  not  differ  materially  from  those  produced  by  similar 
lesions  caused  by  other  microorganisms.  The  prognosis  is  grave. 
A  positive  diagnosis  can  be  made  only  by  demonstrating  the  gonococcus 

'  Horwitz  and  LaiiK:   Wion.  klin.  Woth.,  ISO!},  vol.  vi,  p.  59. 
■  Paulsen:   Miincli.  nicil.  VVocli.,  June  IS,  1901. 
'  Dieulafoy,  G.:   Interiiat.  Clinies,  vol.  iii,  nineteenth  series,  p.  59. 
'■  Hressel:  Miinch.  med.  Woch.,  1903,  vol.  1,  p.  563. 
Thayer  and  Lazear;  Jour.  Exper.  Med.,  1899,  p.  81. 
'  Wyiui,  W.  H.:  Lancet,  London,  1905,  vol.  i,  p.  3.52. 

'Thayer  and  Blumer:    Quoted  by  Dieulafoy:    Intcrnat.  Clinics,  vol.  iii,  nineteenth 
series,  p.  59. 
29 


450  GONORRHEA   IN   WOMEN 

by  means  of  cultures  taken  from  the  sputum,  or  from  the  affected  areas 
after  death,  as  it  is  necessary  to  exclude  the  Micrococcus  catarrhalis, 
which,  morphologically  and  tinctorially,  is  a  sinular  microorganism 
whose  habitat  is  in  the  mouth,  although  it  may  also  be  found  through- 
out the  respiratory  tract. 

GONORRHEAL  PLEURISY 

The  pleura  may  be  attacked  either  in  conjunction  with  a  pneumonia 
or  independently.  Septicemia  is  invariably  present.  To  Mazza^  is 
due  the  credit  for  having  been  the  first  to  demonstrate  gonococci  in 
pure  culture  from  a  pleural  effusion.  Thayer  and  Lazear-  recorded  a 
case  in  which  800  grams  of  fluid  were  found  in  the  right  pleural  cavity 
and  550  grams  in  the  left.  The  liquid  was  rich  in  gonococci.  Gon- 
orrheal pleurisy  is  frequently  bilateral.  The  amount  of  fluid  varies 
in  different  cases.  As  in  all  cases  of  gonorrheal  septicemia,  children 
and  pregnant  women  are  more  susceptible  than  are  non-gravid  fe- 
males. Men  are  more  frequently  attacked  than  women.  Two  cases 
recorded  by  Cardile  occurred  in  young  girls.  Both  were  mild  and 
recovery  took  place.  The  convalescence  was,  however,  prolonged. 
Arthritis  is  a  frequent  complication,  and  may  precede,  accompany,  or 
follow  the  condition.  No  characteristic  symptoms  other  than  those  usu- 
ally produced  by  an  ordinary  pleurisy  have  been  described.  Bertrand* 
states  that  gonorrheal  pleurisy  may  be  either  dry  or  accompanied  by 
an  effusion.   Most  of  the  reported  cases  have  been  of  the  latter  variety. 

The  presence  of  gonococci  in  the  genital  tract,  the  symptoms  of 
septicemia,  an  arthritis,  and,  lastly,  the  demonstration  of  the  gono- 
coccus  in  the  circulating  blood  all  point  to  this  type  of  infection.  The 
prognosis  should  be  extremely  guarded  in  all  cases,  for  while  the  pleurisy 
may  in  itself  be  of  a  mild  grade,  the  general  infection  that  accompanies 
these  cases  may  at  any  time  produce  fatal  complications.  The  diag- 
nosis depends  upon  the  demonstration  of  the  gonococcus  in  the  pleural 
effusion.  It  is  necessary  to  exclude  other  morphologically  similar 
microorganisms.  Mixed  infections  may  occur.  The  following  is  a 
summary  of  authentic  cases  of  gonorrheal  pleurisy  that  have  occurred 
in  the  literature.  They  have  been  obtained  chiefly  from  the  works  of 
Faure-BeauUeu^  and  Geraud  and  Johnston-La vis^ : 

Bardoni  and  Uffreduzzi.^ — The  symptoms  were  those  of  an  ordinary  pleurisy.     The  case 
was  complicated  by  an  arthritis. 

»  Mazza:  Gior.  d.  R.  Accad.  di  Med.  di  Torino,  1S94,  p.  180. 
'  Thayer  and  Lazear:  Jour.  Exper.  Med.,  1899,  p.  81. 
2  Bertrand:  These  de  Paris,  March,  1896,  No.  188. 
<  Faure-Beaulieu :  These  de  Paris,  1906. 

'  Geraud,  H.,  and  Johnston-Lavis,  H.  J.:  Proceed.  Roy.  Soc.  Med.  Clin.  Sec,  June, 
1912,  p.  217. 

» Bardoni  and  Uffreduzzi:   Deut.  med.  Woch.,  1894,  vol.  xx,  p.  484. 


4 


GONORRHEAL    PLEURISY  451 

Bartholow^  reports  a  case  of  septicemia,  during  the  course  of  which  a  pleiuisy  developed. 
Bacteriologic  proof  of  gonococcal  origin  of  the  pleui-isy  is  lacking.  Artliritis  and  con- 
junctivitis were  present,  and  the  specific  organism  was  recovered  from  the  urethra. 

Berlrand.^ — The  disease  occurred  on  the  right  side,  and  was  accompanied  by  fever  and  rapid 
pulse.  Gonococci  were  demonstrated  in  the  pleural  effusion  by  their  morphology  and 
staining  reaction;  the  organism  did  not  grow  on  ordinary  media. 

Cardile? — The  patient  was  a  female,  twenty-three  years  of  age.  Infection  six  weeks  prior 
to  development  of  pleurisy.  Rigors,  fever,  pains  in  right  side  of  chest,  and  cough 
were  the  most  prominent  manifestations.  Aspiration  was  performed  two  weeks  after 
the  onset  of  the  foregoing  symptoms.  Recovery  occurred  after  two  and  a  half  months. 
Gonococci  were  demonstrated  in  the  pleural  effusion  by  both  culture  and  staining 
methods. 

Chiaiso  and  Isnardi.* — Patient  was  a  girl  of  ten  years  of  age,  a  \actim  of  rape.  One  month 
after  infection  fever,  cough,  pain  in  the  chest,  and  objective  symptoms  of  a  pleurisy 
of  tlie  right  side  developed.  Aspiration  was  performed  twice,  and  recovery  occurred 
in  one  month.  The  first  aspiration  was  negative  for  gonococci,  but  the  second  showed 
these  organisms  present  in  the  pleiu-al  effusion. 

Crosby.^ — Male,  thirty-one  years  of  age.  Duration  of  genital  gonorrhea,  three  weeks. 
Symptoms,  partial  delirium,  fever,  high  pulse,  rapid  respirations, — 42, — general  septic 
appearance,  and  signs  of  pleiu'al  effusion.  Purulent  stomatitis,  ophthalmia,  nephritis, 
and  rhinitis  were  present.  Patient  died  shortly  after  admission  to  hospital.  Autopsy 
showed  that  right  pleural  cavity  contained  400  c.c.  of  thin  purulent  fluid,  whereas  the 
left  contained  1000  c.c.  of  similar  material.  The  lungs  were  also  involved,  the  condition 
being  not  so  much  a  pneumonia  as  a  formation  of  local  areas  of  suppuration.  Gonococci 
were  demonstrated  in  the  pleural  effusion  and  in  the  pus  from  the  eyes,  nose,  mouth, 
ethmoid  cells,  trachea,  pelvis  of  the  kidney,  bladder,  urethra,  and  lungs.  Staphy- 
lococci were  also  present  in  the  latter  organs.  The  gonococci  were  recognized  by  their 
morphology  and  staining  properties. 

Dievlafoy^  quotes  Scherrer  as  liaving  reported  the  history  of  a  case  of  gonorrheal  pleurisy. 
The  author  has  been  unable  to  trace  this  reference. 

Fisher''  reports  a  case  of  pleurisy  of  gonorrheal  origin  in  a  man  twenty-six  years  of  age. 
Aspiration  was  performed  twice.  No  gonococci  were  found  in  the  fluid  obtained  by  the 
first  puncture,  but  in  that  from  the  second  gonococci  were  demonstrated  by  their 
morphologic  and  staining  characteristics. 

Geraud  and  Jolinslon-Lnn.'i.^ — ^Male,  .aged  nineteen.  Three  months  after  infection  the 
patient  was  seized  with  violent  pains  in  the  back;  the  temperature  and  pulse  soon 
rose,  the  fe\er  became  hectic,  and  profuse  sweats  occurred.  Temporary  anuria  de- 
veloped. With  the  onset  of  the  fever  the  urethral  symptoms  subsided.  Symptoms 
of  pleurisy  .soon  appeared.  The  case  was  treated  by  incisions  and  drainage.  The 
clinical  course  was  prolonged,  l)ut  a  cure  was  finally  effected.  The  fluid  removed  from 
the  pleural  effusion  was  clear,  yellowish,  and  contained  numerous  floating  clots  of 
yellowish,  glue-like  mucus  and  pseudomembrHtic.  Later,  coMsideralilc  pus  developed. 
The  fluid  first  removed  contained  a  pure  culture  of  gonococci.  A  peculiar  feature  of 
this  case  was  that  there  was  manifest  concordance  between  the  respiratory  and  pulse- 
rates;  these  rates  almost  always  went  down  when  the  temperature  rose.  Diagnosis, 
gonorrheal  empyema. 

Jicinsky." — Male,  aged  twenty-four.  Sudden  sharp  pain  in  the  region  of  the  nipple,  soon 
followed  by  cough,  copious  expectoration,  sweats,  fever,  rapid  pulse,  dyspnea,  and 
other  evidence  of  pleurisy.  The  clinical  duration  of  the  case  was  eight  weeks.  Gono- 
cocci were  found  in  the  pleural  effusion  by  culture  and  staining  methods. 

Krause}" — This  was  a  case  of  double  pleurisy,  in  which  gonococci  were  present  in  the  exudate. 

'  Bartholow,  P.:  Amer.  Jour.  Dermat.  and  Gen.-Urin.  Dis.,  .\pril,  1912,  p.  169. 
'  Bertrand:  Th&e  de  Paris,  1906. 

■'  Cardile:  Clin.  Med.  Ital.,  Milan,  1899,  vol.  xxxviii,  p.  549. 
'  Chiaiso  and  Isnardi:  Giorn.  d.  R.  Accad.  med.  di  Torino,  February,  1894. 
'■  Crosby,  D.:  Amer.  Jour.  Med.  Sci.,  190.5,  vol.  cxxix,  p.  880. 
'•  Dieulafoy:  Internat.  Clinics,  vol.  iii,  nineteenth  scries,  p.  59. 
'  Fisher,  A.:  Ces.  Lckrarske  Listy,  1898. 
"  Geraud  and  Johnston-Lavis:  Loc.  cil. 

''  Jicinsky,  J.  11.:  Jour.  Amer.  Med.  A.s.soc.,  February  4,  1899,  p.  231. 
1°  Krause;  Berlin,  klin.  Wm-h.,  1904,  vol.  xl,  p.  492. 


I 


452  GONOHRHEA   IN   WOMEN 

Mazzn.' — The  patient  was  a  girl  who  became  infected  as  a  result  of  rape.  The  chief  symp- 
toms were  malaise,  fever,  pains  in  the  left  shoulder  and  other  articulations.  Signs  of 
pleurisy  slowly  developed,  and  eight  weeks  later  aspiration  was  performed.  Gonooocci 
were  demonstrated  in  the  pleural  effusion.     The  outcome  of  the  case  is  not  stated. 

Paldrock.- — This  paper  merely  states  that  Sanarelli  cultivated  gonococci  derived  from  a 
pleural  exudate  of  a  girl  aged  eleven  years. 

Prochaska.' — The  patient  was  a  male,  aged  tliirty-seven,  and  a  dyer  by  trade.  Gonorrhea 
was  contracted  about  a  year  prior  to  the  development  of  a  septicemia.  Gonococci 
in  pure  culture  were  recovered  from  the  blood.  One  month  later  symptoms  of  pleurisy 
became  manifest.  Aspiration  was  followed  by  gradual  recovery.  Gonococci  were 
demonstrated  in  the  pleural  effusion. 

Smith.* — Female,  aged  twenty-one  years.  General  gonorrheal  septicemia  following  labor. 
Death  two  months  later.  Bilateral  pleurisy.  Gonococci  recovered  from  pericardial 
and  pleui'al  effusions,  from  aortic  valves,  lung,  Fallopian  tubes,  and  endometrium. 
Gonococci  identified  by  staining  methods  only. 

Thayer  and  Lazear} — The  patient  was  a  male.  The  pleurisy  was  double.  The  right  cavity 
contained  800  grams  of  fluid;  the  left,  550.  The  liquid  was  rich  in  gonococci  which 
were  demonstrated  by  culture  and  staining. 

GONORRHEA  OF  THE  KIDNEY 
If  those  cases  that  are  associated  with  frank,  well-defined  clinical 
septicemia  are  excluded,  gonorrhea  of  the  kidney  is  a  rare  condition. 
In  1911  Nixon,''  in  an  excellent  paper,  reported  the  histories  of  2  cases 
and  was  able  to  collect  10  additional  instances  of  this  condition  from 
the  literature.  Many  other  cases  have  been  recorded  as  being  gono- 
coccal in  origin,  and  in  many  of  these  the  diagnosis  has,  in  all  prob- 
ability, been  correct,  but  absolute  confirmatory  evidence,  founded  upon 
bacteriologic  proof,  is  lacking.  The  gonococcus  may  produce  lesions 
in  the  kidney  either  in  pure  culture  or  in  combination  with  other 
microorganisms'.  Six  of  the  12  cases  studied  by  Nixon  were  cases  of 
mixed  infections,  and  in  6  the  gonococcus  alone  was  present.  Wagner^ 
reviewed  19  cases  collected  from  the  literature,  in  some  of  which  an 
absolute  bacteriologic  diagnosis  was  lacking.  Of  these  19  cases,  10 
were  mixed  infections  and  9  were  probably  purely  gonococcal  in  type. 
Sellei  and  Unterberg*  record  the  histories  of  5  cases,  4  of  which  were 
mixed  infections.  Knorr''  states  that  mixed  infections  are  the  most 
frequent.  The  staphylococcus,  the  streptococcus,  the  Bacillus  coh, 
the  tubercle  bacillus,  the  typhoid  bacillus,  and  other  microorganisms 
have  been  found  in  kidney  lesions  in  conjunction  with  the  gonococcus. 

'  Mazza:  Giorn.  d.  R.  Accad.  di  Med.  di  Torino,  1894,  p.  180. 

-Paldrock:    Der  Gonokokken  Neisseri.     Eine  literiirische  and  Ixikteriologische  ex- 
penmentelle  Studie,  Dorpat,  1907,  p.  91. 

'  Proohaska:  Deut.  Arch.  klin.  Med.,  Leipzig,  1905,  vol.  Ixxxiii,  p.  184. 

*  Smith,  J.  T.:  Cleveland  Med.  Jour.,  October,  1911,  p.  810. 

*  Thayer  and  Lazear:  Jour.  E.xper.  Med.,  1899,  p.  81. 
«  Nixon,  P.  I.:  Surg.,  Gyn.,  and  Obst.,  April,  1911,  p.  331. 
'  Wagner,  F.  R.:  Med.  Rec,  New  York,  October  1,  1910,  p.  568. 
«  Sellei  and  Unterberg:  Berlin,  klin.  Woch.,  1907,  vol.  xliv,  p.  1113. 
^  Knorr,  R.:  Zeit.  f.  gynak.  Urologie,  February,  1910,  vol.  ii,  No.  1. 


GONORRHEA    OF   THE   KIDNEY  453 

There  is  some  doubt  as  yet  that  a  suppurating  lesion  of  the  kidney  can 
be  produced  by  the  gonococcus  alone,  and  many  authorities  believe 
that  a  mixed  infection  is  present  in  all  such  cases.  In  mixed  infections 
the  question  of  priority  is  of  interest,  and  many  authors  believe  that 
the  gonococcus  not  infrequently  prepares  the  soil  for  the  tubercle 
bacillus,  or  perhaps  some  other  variety  of  microorganism.  That  this 
role  is  played  by  the  gonococcus  in  pelvic  lesions  is  now  recognized, 
and  Kolischer^  and  others  have  drawn  attention  to  its  importance. 
In  one  of  Nixon's  cases  it  appeared  that  a  tuberculous  infection  was 
superimposed  on  a  gonorrheal  lesion.  In  Nixon's-  series  the  right 
kidney  was  involved  8  times;  the  left,  .3  times,  and  both  kidneys,  twice. 
Men  are  more  frequently  attacked  than  women,  and  non-pregnant 
women  are  less  susceptible  than  are  children,  gravid  females,  or  women 
during  the  puerperium.  Pyelitis,  pyelonephritis,  and  pj'onephritis 
have  been  described;  the  first  of  these  is  the  most  frequent  in  those 
cases  in  which  gonococci  alone  were  present. 

Modes  of  Infection. — The  gonococcus  may  reach  the  kidney  by 
way  of  the  general  circulation,  as  the  result  of  a  septicemia,  or  it  may 
result  from  an  ascending  infection.  In  men  the  infection  iseems  to 
be  conveyed  most  frequently  by  way  of  the  circulatory  system,  whereas 
among  women  ascending  infections  appear  to  predominate,  but  the 
number  of  recorded  cases  from  which  to  draw  accurate  conclusions 
regarding  this  point  is  as  yet  small. 

Hematogenous  Infection. — The  existence  of  a  gonorrheal  septicemia 
has  been  amply  proved.  HowelP  and  other  phj'siologists  have  shown 
that,  of  the  total  (luantity  of  blood  that  passes  through  the  heart  in 
one  minute,  5  or  G  per  cent,  is  forced  through  the  kidney  in  a  like  in- 
terval of  time.  In  view  of  this  fact  it  would  seem  that  renal  lesions 
should  be  more  frequent  in  cases  of  septicemia  than  they  are.  Thus, 
in  (,'ole's^  series  of  29  cases  of  general  gonococcal  infection,  none  showed 
any  active  involvement  of  the  kidney.  It  has,  however,  been  amply 
proved  by  Dudgeon,*  .Geraghty,^  and  others  that  pathogenic  micro- 
organisms may  pass  through  the  kidney  without  producing  severe 
lesions.  In  frank  septicemias  embolic  renal  abscesses  are,  however, 
not  infrequent. 

Ascending  Infections. — Certain  conditions  seem  to  favor  an  as- 
cending infection;    among  these  are  menstruation,  pregnancy,  labor, 

'  Kolischer,  G.:  Surg.,  Gyn.,  and  Obst.,  .'\pril,  101 1,  p.  3(1. 

■  Nixon:  Surg.,  Gyn.,  and  Obst.,  April,  1911,  p.  3:il. 

'  Howell,  \V.  II.:  Text-book  of  Physiology,  1905,  p.  749. 

'  Cole:  O.sler's  Modern  Medicine,  1908,  vol.  iii,  pp.  SS-120. 

■'  Dudgeon:  Lancet,  1908,  vol.  i,  p.  015. 

'  Geraghty:  Tran.s.  Amer.  A.ssoc.  Gcn.-Urin.  Surg.,  1909,  vol.  iv,  p.  200. 


454  GONORRHEA    IN    WOMEN 

irritation  either  from  a  calculus  or  from  a  preexisting  disease,  such  as 
tuberculosis  or  syphilis,  anemia,  or  other  conditions  that  diminish  the 
tonicity  of  the  tissues  of  the  ureter  or  prevent  the  free  downward  flow 
of  the  urine.  Lewis'  reports  the  history  of  an  interesting  case  in  which 
three  ureters  were  present,  only  one  of  which  was  attacked.  This 
author  believes  that  anomalies  of  the  ureter  favor  an  ascending  in- 
fection. Cystitis  or  trigonitis  of  gonorrheal  origin  is  by  no  means  un- 
common. That  ascending  infections  are  not  more  frequent  can  be 
accounted  for  only  by  the  fact  that  the  vesical  openings  of  the  ureters 
are  normally  tightly  closed  by  a  sphincteric  action  except  during  the 
escape  of  urine,  and  that  the  downward  flow  of  the  fluid  washes  away 
infection  and  tends  to  prevent  an  extension  of  the  inflammation  up- 
ward. The  epithelium  of  the  ureter  is  not  of  the  type  usually  at- 
tacked by  the  gonococcus. 

Sampson^  has  shown  that,  in  the  case  of  ordinary  microorganisms, 
obstruction  to  the  ureter  is  a  strong  predisposing  factor  to  infection 
of  the  kidney.  This  observer  experimented  on  dogs,  tied  the  ureters, 
and  injected  2  c.c.  of  a  twenty-four-hour  culture  of  Staphylococcus 
aureus  into  the  jugular  vein,  and  in  every  instance  the  kidney  whose 
ureter  had  been  ligated  became  infected.  It  would  seem,  therefore, 
that  a  stricture  of  the  ureters  would  also  act  as  a  predisposing  factor 
in  a  gonorrheal  infection  of  the  hematogenous  variety.  Dowd^  and 
others  assert  that  an  ascending  infection  may  occur  without  bladder 
involvement.  In  the  case  of  the  gonococcus,  an  organism  that,  in  the 
genital  tract,  at  least  travels  by  continuity,  it  appears  more  probable 
that  ascending  infections  are  usually  caused  by  a  direct  surface 
extension  upward  from  the  trigone.  Cases  in  which  gonorrhea  of 
the  kidney  has  been  recorded  without  gross  vesical  involvement, 
and  that  were  ascending  infections,  can  probably  be  accounted  for 
by  the  fact  that  the  cystitis  may  have  disappeared  by  the  time  the 
renal  symptoms  became  manifest,  or  that  a  low-grade  trigonitis  may 
have  been  present  and  been  overlooked  on  cystoscopic  examination. 
Other  routes  of  ascending  infection  are,  however,  possible.  Samp- 
son,* by  methods  of  injection,  has  demonstrated  the  existence  of  the 
vesico-utero-ovario-renal  circulation;  also  that  infection  may  pass 
through  the  blood-vessels  of  the  ureter,  and  that  there  is  free  com- 
munication between  the  arteriovenous  circulation  of  the  bladder  and 
the  ureter  throughout  the  length  of  the  latter.     The  possibility  of  an 

'  Lewis,  B.:  Jour.  Cutan.  and  Gen.-Urin.  Dis.,  September,  1900,  p.  395. 
-  Sampson,  J.  A.:  Johns  Hopkiiis  Hosp.  Bull.,  1903,  vol.  xiv,  p.  334. 
'  Dowd,  J.  H.:  Med.  Rec,  New  York,  1898,  vol.  liii,  p.  939. 
*  Sampson:  Johns  Hopkins  Hosp.  Bull.,  1903,  vol.  xiv,  p.  334. 


GONORRHEA    OF    THE    KIDNEY  455 

ascending  infection  traveling  along  the  "lymphatics  must  also  be  con- 
sidered. In  some  types  of  infection  this  is  probably  the  most  impor- 
tant route.  Stewart^  and  Kumita-  have  shown  that  there  is  a  close 
connection  between  the  lymphatics  of  the  ureter  and  those  of  the 
perinephritic  tissue.  Uysing'  and  others  have  demonstrated  the 
presence  of  gonococci  in  the  lymphatics  and  lymph-stream.  This 
route  of  infection  is,  however,  probably  rare  in  the  case  of  gonorrhea. 
Symptoms. — The  number  of  recorded  cases  from  which  to  draw 
accurate  conclusions  are  as  yet  too  few.  Thus,  the  period  between  the 
onset  of  the  infection  in  the  genitaUa  and  the  appearance  of  renal 
symptoms  is  quite  variable,  and  no  rule  for  this  can  be  laid  down.  In 
Weisswange's^  case  the  symptonis  appeared  during  the  puerperium, 
six  years  after  the  original  infection.  Conversely,  Marcuse^  records 
the  historj'  of  a  case  in  which  the  renal  symptoms  appeared  ten  days 
after  the  onset  of  urethritis.  In  both  the  hematogenous  and  the  as- 
cending infection  it  would  seem  that  renal  involvement  would  be  more 
likely  to  occur  during  the  chronic  than  during  the  acute  stage  of  the 
original  infection,  as  both  septicemia  and  cystitis  are  more  prone  to 
occur  at  this  time.  The  symptoms  of  renal  involvement  do  not  differ 
markedly  from  those  produced  by  similar  lesions  resulting  from  other 
microorganisms.  The  onset  is;  as  a  rule,  gradual,  although  in  cases 
supposed  to  be  gonorrheal  in  tj'pe,  the  histories  of  which  have  been 
reported  by  Ravogli,''  the  appearance  of  the  renal  symptoms  was 
sudden  and  acute.  Backache — pain  in  the  region  of  the  kidney,  some- 
times radiating  to  the  groins — is  often  present.  If  the  case  is  one  of  an 
ascending  infection,  the  symptoms  of  either  an  antecedent  or  a  con- 
comitant cystitis  can  nearly  always  be  elicited.  In  this  variety  pain  or 
tenderness  along  the  course  of  the  ureter  is  frequent.  In  the  hematog- 
enous variety  the  symptoms  of  a  septicemia,  with  not  infrequently  an 
arthritis  or  other  metastatic  manifestations,  are  generally  present. 
Fever,  with  its  accompanying  phenomena,  is  often  olisorved,  but  varies 
with  the  stage  of  the  disease  and  the  acuteness  of  the  infection.  Gas- 
tric disturbances,  such  as  nausea,  vomiting,  loss  of  appetite,  and  coated 
tongue,  may  occur.  Either  diarrhea  or  constipation  maj^  be  present, 
but  the  former  is  the  more  common  condition.  As  the  disease  ad- 
vances anemia,  loss  of  strength  and  weight,  and  more  or  less  prostra- 
tion may  result,  or  the  patients  may  be  well  nourished.     The  urine 

'  Stewart,  L.  F. :  University  of  Pennsylvania  Med.  Bull.,  1910,  vol.  xxiii,  p.  233. 

'  Kumita:  Arch.  f.  Anat.  u.  Entwicklungsgesch.,  Leipzig,  1909,  p.  49. 

'  Uysing:   Inaug.  Dissert.,  Kiel,  1900. 

*  Weisswange:  Miinch.  med.  Wochenschr.,  1908,  vol.  Iv,  p.  9(17. 

'  Marcuse,  \i.:  Monats.  f.  Urologie,  Berlin,  1902,  vol.  vii,  p.  127. 

«  Havogli:  .\iner.  Jour.  Urology,  New  York,  1906,  vol.  iii,  No.  11,  p.  551. 


456  GONORRHEA    IN    WOMEN 

contains  albumin,  renal  epithelium,  casts,  blood,  pus,  and  gonococci, 
the  latter  are  often  demonstrable  in  the  casts  and  in  the  renal  epithe- 
lium. The  urinary  findings  naturally  vary  with  the  stage  of  the  dis- 
ease and  the  variety  of  lesion  present.  At  first  the  amount  of  urine  is 
diminished,  but  later  polyuria  often  exists.  Some  writers  lay  great 
stress  upon  the  diagnostic  significance  of  large  quantities  of  albumin 
in  the  urine  in  these  cases.  The  actual  value  of  the  finding  of  albu- 
minuria in  formulating  the  diagnosis  of  the  condition  is  still  undeter- 
mined, but  is  probably  not  great.  Of  far  greater  value  in  the  deter- 
mination of  the  condition  of  the  kidney  is  the  a;-ray,  combined  with 
ureteral  catheterization  and  the  injection  of  collargol  or  argyrol. 
Renal  abscesses  can  be  frequently  detected  by  this  method,  and  the 
urine  for  bacteriologic  examination  can  be  obtained  directly  from  the 
kidney.  In  certain  suspected  cases  ureteral  catheterization  is  not 
justifiable  on  account  of  the  danger  of  spreading  the  infection.  The 
presence  of  gonococci  within  the  tube-casts  is  very  suggestive. 

Diagnosis. — This  depends  upon  the  demonstration  of  the  gono- 
cocci'in  the  kidney — either  in  the  urine  in  the  kidney,  in  the  pus  in  the 
kidney,  or  in  the  renal  tissue.     No  other  evidence  is  acceptable. 

Prognosis. — This  should  be  guarded,  but  depends  largely  upon 
the  individual  case,  as  the  pathology  may  vary  from  a  moderate  degree 
of  inflammation  to  large  single  or  multiple  abscesses.  In  cases  of 
general  infection  the  prognosis  is  less  favorable  than  when  the  con- 
dition has  resulted  from  an  ascending  infection.  Tuberculosis  may  be 
secondary  to  gonorrhea  of  the  kidney.  Gonorrheal  renal  lesions  are 
sometimes  extremely  chronic.  In  one  of  Lewis'^  cases  it  had  possibly 
existed  for  twelve  years,  and  during  that  period  the  patient  had  pus  in 
the  urine  and  other  symptoms  referable  to  the  kidney ;  in  this  case  an 
interstitial  nephritis  and  numerous  abscess  cavities  were  present  that, 
from  their  appearance,  had  apparently  existed  for  a  long  time.  On 
the  other  hand,  one  of  Asahara's^  cases  was  characterized  by  fulminat- 
ing symptoms.  The  patient,  a  girl  of  sixteen,  was  brought  to  the 
Moabit  Hospital,  in  Berlin,  unconscious.  A  diagnosis  of  sepsis,  ap- 
pendicitis, and  peritonitis  was  made.  An  autopsy  revealed  gonococci 
in  the  pus  of  a  renal  abscess  and  in  the  lungs.  The  case  was  one  of 
gonococcal  septicemia. 

Treatment. — This  depends  upon  the  lesions  present,  the  stage  of 
the  disease,  and  the  condition  of  the  individual  patient.  In  general, 
the  treatment  is  that  usually  employed  for  similar  lesions  produced  by 
other  microorganisms.     During  the  early  stage  of  the  disease,  and  when 

'  Lewis,  B.:  Jour.  Cutan.  and  Gen.-urin.  Dis.,  September,  1900,  p.  395. 

2  Asahara:  "U^ber  Metastasen  den  GonorrhSe,"  Inaug.  Dissert.,  Berlin,  1898. 


GONORRHEA    OF    THE    KIDNEY  457 

the  kidne}-  peh-is  approaches  the  normal,  lavage  with  silver  salts  is 
indicated.  This  treatment  is  often  successful.  If  the  disease  is  ex- 
tensive and  much  destruction  of  renal  tissue  has  taken  place,  neph- 
rectomy or  nephrotomy  offers  the  best  hope  of  cure.  Constitutional 
treatment,  similar  to  that  usually  employed  for  nephritis,  should  be 
instituted.  During  the  acute  stage  the  diet  should  consist  largely  or 
entirely  of  milk;  alkaline  drinks  are  sometimes  beneficial.  Urinary 
antiseptics,  such  as  salol  or  urotropin,  may  be  prescribed.  If  the 
condition  is  the  result  of  an  ascending  infection,  the  cystitis  or  trigo- 
nitis  must  be  treated,  whereas  in  all  cases  the  primary  focus  should 
if  possible  be  eradicated.  In  the  chronic  cases  tonics  and  efforts  to 
improve  the  general  hygiene  should  be  employed.  The  following 
authentic  cases  of  pyelitis,  in  which  the  gonococcus  alone  was  present, 
have  been  recorded : 

Dodge.'' — Female,  who  three  weeks  after  marriage  developed  a  eystiti.s.  Later,  pain  and 
tenderness  in  the  region  of  the  left  kidney  developed.  The  catheterization  of  the  left 
ureter  showed  a  cloudy,  pus-laden  renal  urine,  from  which  undoubted  gonococci  were 
demonstrated.  The  kidney  was  irrigated  with  boric-acid  solution,  followed  by  the 
instillation  of  a  dram  of  25  per  cent,  argyrol  solution.  The  symptoms  disappeared  at 
once  and  no  gonococci  were  demonstrable  after  the  third  treatment. 

Iliiqncr.- — Male,  aged  thirty-five  years.  Patient  had  contracted  gonorrhea  twice — the  first 
attack  ten  years,  and  the  second  five  or  six  weeks,  before  renal  symptoms  developed. 
The  first  symptoms  consisted  of  pain  and  tenderness  along  the  course  of  the  right  ureter 
and  in  the  inguinal  region,  with  slight  elevation  of  temperature.  A  urethritis  and 
prostatitis  cleare<l  up  under  treatment,  but  pyuria  persisted.  The  cystoscope  revealed 
a  trigonitis,  and  catheterization  of  the  right  ureter  withdrew  pus-laden  urine  from  which 
undoubted  gonococci  were  demonstrated.  The  use  of  argyrol  and  the  x-ray  showed  the 
renal  pelvis  to  be  of  normal  size.  Treatment  consisted  of  lavage  with  a  1  per  cent, 
solution  of  silver  nitrate  and  the  injection  of  vaccines.     A  cure  resulted. 

Lchr} — Male,  aged  twenty-seven,  seen  November  6,  1911,  complaining  of  a  urethral  dis- 
charge and  dysuria.  Patient  had  two  previous  attacks  of  gonorrhea,  from  which 
he  recovered  promptly.  The  present  attack  began  October  .5,  1911.  Examination 
showed  a  scanty  purulent  discharge  that  contained  gonococci.  There  was  marked 
terminal  hematuria.  The  prostate  and  seminal  vesicles  were  apparently  normal. 
The  hematuria  and  pain  subsidefl  in  about  two  weeks  under  rest  and  internal  medica- 
tion. Local  treatment  w;is  instituted,  but  in  spite  of  all  efforts  the  urine  remained 
cloudy  and  continued  to  show  gonococci  until  .January  20th,  when  cystoscopic  examina- 
tion revealed  purulent  urine  coming  from  the  left  ureter.  This  ureter  was  eatheterized 
and  some  of  the  urine  inoculated  on  seruni-agar.  The  report  from  the  laboratory 
showed  a  pure  culture  of  gonococci.  Stock  and  autogenous  vaccines  were  tried,  but 
without  beneficial  result.  On  February  15th  pelvic  lavage  with  silver  nitrate  was 
begun.  After  four  of  these  treatments  with  solutions  of  silver  nitrate,  varying  in 
strength  from  1:  .5000  to  1:  2.500,  the  urine  became  clear  and  remained  so,  and  cultures 
on  seruin-agar  proved  negative. 

L<m.i.* — Male,  aged  twenty-four  years.  Six  years  prior  to  the  onset  of  renal  symptoms 
the  patient  suffered  from  repeated  attacks  of  urethritis  which  were  resistant  to  treat- 
ment. Lewis  suspected  renal  involvement.  On  cystoscopic  examination  three  ureteral 
openings  were  seen.     Ureteral  catheterization  of  the  right  and  left  ureters  showed  clear 

•  Dodge,  \\'.  T.:  Jour.  Mich.  State  Med.  Soc,  100.5,  vol.  iv,  p.  58. 

'  llagner,  I".  R.:  Trans.  .Vmer.  .\ssoc.  Gcn.-urin.  Surg.,  1910,  vol.  v,  p.  16;  also  Med. 
Kec,  New  York,  1910,  vol.  Ixxviii,  p.  SG-S. 

'  Lehr,  L.  C:  Jour.  Amer.  Med.  Assoc,  April  27,  1912,  p.  1307;  also  Jour.  .Vmer. 
Med.  A.K.SOC.,  July  0,  1912,  p.  36. 

'  Lewis,  B.:    Med.  He-  ,  New  York,  October  6,  19()i;,  p.  .521. 


458  GONORRHEA    IN   WOMEN 

urine.  A  catheter  passed  into  the  central  opening  withdrew  cloudy,  pus-containing 
urine,  from  which  gonococci  were  demonstrated.  Lavage  with  silver  nitrafe  solution 
effected  a  cure,  and  no  further  uretliral  symptoms  developed.  Lewis  believes  that  the 
recurrences  of  the  urethritis  were  due  to  the  reinfection  from  the  kidney. 

Marcuse.^ — Case  1. — Male,  aged  twenty-five;  gave  a  history  of  urethritis  twice.  The 
first  attack,  two  years,  and  the  second,  three  months,  before  the  onset  of  the  renal 
symptoms.  The  chief  symptom  was  pain  in  the  right  side,  in  the  region  of  the  kidney. 
By  ureteral  catheterization  on  the  right  side  urine  was  obtained  that  was  cloudy  and 
contained  pus  and  typical  gonococci.  After  two  recurrences  the  symptoms  were  finally 
cured  by  lavage.  The  kidney  was  hydronephrotic  and  had  a  capacity  of  100  c.c.  of 
fluid. 
Case  2. — Male,  aged  twenty-two  years.  The  onset  of  the  renal  symptoms  occurred  ten 
days  after  the  beginning  of  a  urethritis.  The  cliief  symptom  was  pain  and  tenderness 
in  the  renal  regions.  On  the  twentieth  day  after  the  appearance  of  lu'etliritis  ui'eteral 
catheterization  showed  cloudy,  pus-laden  urine  from  the  right  side,  wliich  contained 
numerous  typical  gonococci,  and  a  clear  mine  from  the  left  kidney.  The  case  was  treated 
by  lavage  with  silver  nitrate  solution,  and  recovery  ensued. 

SeUei  and  Unlerberg.'' — Patient  was  a  man  who  had  had  symptoms  of  urethritis,  prostatitis, 
and  cystitis  for  about  ten  months.  The  usual  treatment  resulted  in  some  improvement. 
At  about  this  time  moderate  pain  and  tenderness  developed  in  the  region  of  the  right 
kidney,  and  pyeUtis  was  suspected.  No  fever  or  other  manifestation  of  a  general  in- 
fection was  present.  The  cystoscope  revealed  a  well-marked  trigonitis,  and  the  urine 
from  the  right  kidney,  obtained  by  ureteral  catheterization,  contained  diplococci 
that  were  subsequently  grown  in  culture-media,  and  that  corresponded  morphologically, 
tinctorially,  and  culturally  to  the  gonococcus.  The  urine  was  cloudy  and  contained 
pus.     The  case  was  cured  by  lavage. 

The  foll(3wing  is  the  brief  history  of  a  case  of  gonorrhea  of  the  kidney 
that  occurred  in  the  Gynecologic  Department  of  the  University  of 
Pennsylvania : 

Female,  aged  thirty-one.  Purulent  leukorrhea  since  marriage,  six  years  ago.  Symp- 
toms of  cystitis  for  the  last  tliree  months.  Examination  shows  an  indurated  drainage  tract 
leading  from  an  old  suburethral  abscess  to  a  point  a  little  above  the  exit  of  Bartholin's 
gland.  Gonococci  were  recovered  by  smears  from  the  urethra,  cervix,  Bartholin's  gland, 
remains  of  old  abscess,  and  bladder.  Cystoscopic  examination  shows  an  easily  permeable 
stricture  of  the  uretlu-a.  The  trigone  was  the  seat  of  a  low-grade  chronic  inflammation. 
Just  below  the  opening  of  the  left  ureter  was  an  ulcer  1  or  2  cm,  in  diameter.  Clear  urine 
was  expelled  from  the  right  ureter,  and  pus  and  urine  from  the  left.  Ureteral  catheteriza- 
tion confirmed  the  above,  and  from  the  urine  thus  obtained  from  the  left  kidney  gonococci 
were  demonstrated.  The  case  is  still  in  the  ward,  so  that  the  result  of  treatment  cannot  as 
yet  be  stated.  It  would  appear,  from  our  present  finding,  that  there  is  httle  doubt  that  the 
case  is  one  of  an  ascending  infection.  A  positive  diagnosis  of  this  variety  of  lesion  is  not 
yet  possible. 

The  following  are  the  abstract  reports  of  cases  of  pyelonephritis, 
which,  with  one  exception,  were  probably  due  to  mixed  infections: 

Franco.'— Female,  aged  twenty-six.  Symptoms  of  ureteritis  and  pyonephrosis  on  the  right 
side  for  four  years.  Catheterization  of  kidney  showed  gonococci  in  pure  culture. 
Nephro-ureterectomy  was  followed  by  a  cure.  Examination  of  the  kidney  showed  it 
to  have  been  converted  into  a  large  pyonephritic  sac.  Microscopically,  it  showed 
changes  reseinbhng  those  found  in  chronic  parenchymatous  neplu-itis,  and  numerous 
foci  of  chronic  interstitial  nephritis.  Severe  pyelitis  and  ureteritis  were  present. 
Franco  is  in  doubt  as  to  whether  the  condition  was  due  to  an  ascending  or  a  hema- 
togenous infection. 

Gerster.* — Male,  ten  years  of  age.     Renal  symptoms  developed  three  weeks  after  the  onset 

'  Marcuse,  B.:  Monats.  f.  Urologie,  Berlin,  1902,  vol.  vii,  p.  127. 

-  Sellei,  J.,  and  Unterberg,  H.:  Berlin,  klin.  Woch.,  1907,  vol.  xliv,  p.  1113. 

'  Franco,  E.  E.:  Folio  Urologica,  February,  1912,  vol.  vi.  No.  8,  p.  552. 

<  Gcrster,  A.  G.:  New  Yorker  med.  Monatsschr.,  New  York,  1897,  vol.  ix,  p.  189. 


GONORRHEA    OF   THE    KIDNEY  459 

of  a  .urethritis.  The  symptoms  were  acute.  Nephrectomy,  followed  by  autopsy, 
showed  both  kidneys  involved.  A  number  of  abscesses  were  present  in  the  right  kid- 
ney, and  a  single  small  abscess  in  the  left  kidney;  also  a  small  abscess  in  the  prostate. 
The  bladder  mucosa  was  hemorrhagic.  Gonococci  were  demonstrated  in  the  kidney 
by  staining  methods  and  cultures. 

LewisJ — Male,  fifty-four  years  of  age.  The  patient  was  admitted  to  the  hospital  in  a  semi- 
conscious condition.  Denied  having  had  urethritis.  Had  suffered  for  twelve  years 
from  more  or  less  chronic  symptoms  referable  to  the  kidney.  The  patient  died,  and 
autopsy  revealed  tuberculous  cavities  in  both  lungs.  The  right  kidney  was  enlarged 
and  contained  a  number  of  abscesses,  from  the  pus  of  wliich  gonococci  were  demon- 
strated by  staining  methods.  The  case  may  have  been  a  mixed  infection  with  the 
tubercle  bacilli,  as  there  is  no  record  that  the  renal  tissue  was  examined  for  these  micro- 
organisms. 

Nixon.^ — Cfise  7.— Female.  Date  of  original  infection  not  definitely  determined,  but  had 
"considerable  leukorrheal  discharge  lately."  General  health  poor  for  four  years. 
Pains  in  left  side  and  domi  the  thighs  for  four  months.  Frequent  urination.  Lost 
10  pounds  in  weight.  During  the  last  few  montlis  patient  has  had  what  she  termed 
"good  days"  and  "bad  days."  For  several  days  she  would  feel  well  anil  the  urine 
would  be  clear.  Then  pain  in  the  side  would  appear,  and  the  urine  would  become 
cloudy  and  the  urination  frequent.  Examination  revealed  an  indefinite,  fum,  tender 
mass  in  the  left  lumbar  region.  Gonococci  were  recovered  from  the  urethra.  The 
urine  was  cloudy  and  contained  pus.  Cystoscopic  examination  showed  the  bladder 
normal  except  for  slight  redness  about  the  left  ureteral  orifice.  Ureteral  catheteriza- 
tion showed  clear  urine  from  the  right  kidney  and  an  obstruction  2  cm.  up  the  left 
ureter.  No  tubercle  bacilli  in  urine.  At  nephrotomy  an  abscess  containing  150  c.c. 
of  pus  was  evacuated,  from  which  gonococci  were  grown.  Two  months  later  the 
patient  returned,  with  a  persistent  sinus  at  the  site  of  the  original  operation,  in  the  dis- 
charge from  which  tubercle  bacilli  were  demonstrated.  Nixon  states  that  it  is 
impossible  to  determine  absolutely  which  microorganism  was  the  primary  invader. 
Case  2. — -Negress,  aged  forty-eight  years.  Renal  symptoms  began  thirteen  years  ago. 
Attacks  of  pain  in  the  left  side,  which  came  on  irregularly  at  first,- — two  or  tlu-ee  a  year, 
— but  now  occur  every  month  or  so.  Pain  starts  in  the  region  of  the  left  kidney  and 
radiates  along  ureter.  The  pain  is  sharp,  with  frequent  colicky  exacerbations,  and  is 
sometimes  accompanied  by  nausea  and  vomiting.  There  is  frequency  of  urination. 
Examination  was  negative  except  for  a  purulent  leukorrhea.  Temperature  varied  l)o- 
tween  99°  and  100°  F.;  pulse,  90;  leukocytes  numbered  74,000.  Urine  acid,  specific 
gravity,  1015,  contained  albumin  arid  much  pus.  Cystoscopic  examination:  bladder 
normal;  ureteral  orifices  normal.  Purulent  lu'ine  seen  escaping  from  the  left  side. 
Ureters  catheterized  and  cultures  of  renal  urine  made.  Six  milhgrams  of  phenolsul- 
phophthalcin  given  intramascularly  and  urine  collected  for  one  hour. 

Right  Kidnet  Left  Kidnev 

Time  of  appearance  of  drug S  minutes 10  minutes. 

Amount  of  urine 210  c.c 125  c.c. 

Amount  of  drug 40  per  cent 12  per  cent. 

Urea  per  liter 14  gm 2  gm. 

Microscopic  examination Negative Many  pus-cells. 

Operation,  nephrectomy  and  partial  ureterectomy. 

Gross  DescripUon. — The  specimen  consists  of  the  kidney  and  5  cm.  of  ureter.  The 
hardened  kidney  measures  5  x  5  x  4.5  cm.  The  capsule  over  the  lower  thini  strips 
easily,  whereas  over  the  upper  two-thirds  it  is  densely  adherent.  The  contrast 
between  these  two  areas  with  the  capsule  stripped  is  quite  marked:  the  lower  part  is 
yellow  in  color  and  has  a  smooth  surface;  the  upper  part  presents  a  brownish,  mottled 
appearance;  its  surface  is  rough,  and  shows  several  deep  indentations;  the  mottled 
appearance  is  due  to  scattered  areas  of  superficial  hemorrhage.  On  section  the  con- 
trast is  equally  well  marked;  at  the  lower  pole  there  is  an  area  of  yellowish-gray 
kidney  ti.ssue,  3x2  cm.,  which  is  doubtless  a  hypertrophy,  compensatory  in  nature; 
Malpighian  bodies  are  easily  seen;  the  cortical  stria;  are  obliterated.  In  the  upper 
two-thirds  there  is  no  renal  tissue  left;  it  has  been  replaced  by  five  or  six  absce.s.s- 
cavities,  which  vary  from  1  to  2  cm.  in  diameter;  these  cavities  correspond  to  I  he 
indentations  noticed  on  the  surface.  They  are  lined  by  rather  firm  granulation  tissue, 
and  all  communicate  with  the  kidney  pelvis  more  or  less  directly,  and  into  those 

'  Lewis,  n.:  Jour.  Cutan.  and  Gcn.-urin.  Dis.,  New  York,  1900,  vol.  wiii,  p.  395. 
=  Nixon,  P.  L:  Surg.,  Gyn.,  and  Obst.,  1911,  vol.  xii,  No.  4,  p.  .Wl. 


460  GONOREHEA   IN   WOMEN 

nearest  the  pelvis  the  pelvic  epithehum  can  be  seen  extending,  some  of  them  appearing 
to  be  almost  completely  lined  by  epithelium.  The  abscesses  are  separated  by  dense 
fibrous  tissue.  The  pelvis  is  contracted  and  greatly  thickened.  The  epithelium  is 
much  increased  in  thickness,  and  is  here  and  there  heaped  up  into  white  elevations 
above  the  surface,  which  resemble  leukoplakia  buccahs.  There  is  nothing  to  suggest 
tuberculosis. 
Microscopic  Description. — The  renal  parenchyma  shows  evidence  of  compensatory  hyper- 
trophy; the  tubules  are  somewhat  distended;  the  cells  are  shghtly  flattened  and  have 
undergone  parenchymatous  degeneration.  The  greater  part  of  the  kidney  is  made 
up  of  scar-tissue,  in  which  can  be  seen  old  and  young  fibroblasts,  scattered  round-cells, 
and  round-cells  collected  in  places,  especially  in  the  region  of  the  pelvis,  into  definite 
lymph-nodes  with  germinal  centers.  Section  of  the  abscess-walls  shows  them  to  be  lined 
for  the  most  part  by  granulation  tissue  with  a  loosely  attached  exudate;  in  the  region 
of  the  kidney  pelvis  the  pelvic  epithelium  has  proliferated,  so  that  in  places  a  single 
layer  of  swollen  cells  completely  encircles  the  cavity.  The  epithelium  of  the  kidney 
pelvis,  notably  in  the  white  patches  previously  mentioned,  has  undergone  a  remarkable 
metaplasia — a  transformation  from  the  transitional  to  the  squamous  type.  The  cells 
have  increased  in  number,  and  those  on  the  surface  are  flattened  and  have  lost  their 
nuclei.  In  a  word,  the  epithelium  is  not  dissimilar  to  skin  epithelium.  There  is  no 
evidence  of  acute  infection,  and  nowhere  is  there  anything  that  resembles  tuberculosis. 
Undoubted  gonococci  were  demonstrated  in  the  pus  from  the  renal  abscess  by  cultures 
and  staining.  Typhoid  bacilli  were  grown  from  the  renal  urine  of  the  infected  kidney. 
The  patient  had  had  typhoid  fever  twenty-five  years  previously. 

Weissivangc.^ — Female,  aged  thirty-four  years.  Contracted  gonorrhea  six  years  before 
onset  of  renal  symptoms.  During  puerperium  developed  symptoms  of  sepsis  and  pain 
in  right  renal  region.  The  kidney  was  tender  and  enlarged.  The  urine  contained 
gonococci.  Under  medical  treatment  the  patient  improved  and  was  subsequently  dis- 
charged from  the  hospital,  but  two  months  later  returned  with  a  recurrence  of  the  renal 
symptoms.  Nephrectomy  was  performed.  The  kidney  was  enlarged,  and  in  the  upper 
pole  was  a  moderate-sized  abscess.  The  remainder  of  the  kidney  appeared  normal. 
Gonococci  in  the  wall  of  the  abscess  were  demonstrated  by  staining.  No  cultures  were 
taken,  so  that  the  possibiUty  of  other  microorganisms  having  been  present  cannot  be 
excluded. 

Cases  of  goiion-hea  of  the  kidney  associated  with  frank  gonorrheal 
septicemia  have  been  reported  by  Asahara-  (2  cases,  one  gonococci 
alone  and  the  other  a  mixed  infection),  Wynn'  (mixed  infection),  and 
others. 

The  following  authors  have  reported  the  histories  of  cases  of  gonor- 
rhea of  the  kidney,  in  many  of  which  a  correct  diagnosis  undoubtedly 
was  made,  but  positive  bacteriologic  proof,  as  instanced  by  the  re- 
covery of  the  gonococcus  from  the  urine  or  pus  in  the  kidney  or  from 
the  kidney  .substance,  is  lacking:  Bockart,^  Fiirbringer,"  Balzer  and 
Souplet,''  Neuendorff,^  Kelly,«  Mendelsohn,^  Schmidt,'"  Berg,'i  Cum- 

'  Weisswange,  F.:  Miinch.  mod.  Wochenschr.,  1908,  vol.  Iv,  p.  967. 
=  Asahara:   "Uber  Metastasen  den  Gonorrhoe,"  Inaug.  Diss.,  Berlin,  1898. 
"  Wynn,  W.  H.:  Lancet,  London,  1905,  vol.  i,  p.  352. 

■'  Boekhart,  M, :  "Beitrage  z.  Atiol.  u.  Path,  des  Harnrohrentrippers,"  Vierteljahresschr. 
f.  Dermat.  u.  Syph.,  Vienna,  1883,  vol.  x,  p.  3. 

'  Furbringer,  P.:  Die  innere  Krankheiten  der  Harn- und  Geschlechtsorgane,  Berlin, 
1890. 

'■  Balzer  and  Souplet:  Annal.  d.  dermat.  et  syph.,  Paris,  1S92,  vol.  iii,  p.  113. 

'Neuendorff,  F.:  Inaug.  Diss.,  Berlin,  1892. 

*  Kolly,  H.  A.:  Johns  Hopkins  Hosp.  Bull.,  1895,  vol.  vi,  p.  19. 

»  Mendelsohn:  Berlin,  klin.  Woch.,  1896,  vol.  x.xxiii,  p.  1509. 

'"Schmidt:  Inaug.  Diss.,  Munich,  1897. 

"  Berg,  H.  W.:  Med.  Rec,  New  York,  1899,  vol.  Iv,  p.  602. 


GONORRHEA  OF  THE  NERVOUS  SYSTEM  461 

ston/  Young,-  Cabot, ^  Ravogli,^  Denis,^  Stoyantchoff,"  Kiister  and 
Wagner,^  Waelsch,*  Wladimirskj',"  Carlslaw,'"  Aronstam,"  Dowd,^- 
Stojanschoff  and  Rosenfeld,"  and  Pollock  and  Harrison^ ^  (merely  men- 
tion a  case  while  discussing  treatment).  Mortz'=  has  recently  con- 
tributed a  valuable  paper  on  this  subject. 

Perinephritis 
Miyata"^  reports  the  history  of  a  case  of  this  rare  conditioii.  The 
patient  was  a  man  who  had  a  gonorrheal  urethritis  four  years  pre- 
viously. The  patient  was  suddenly  seized  with  severe  pains  in  the 
right  hip  and  loin.  The  pain  was  accompanied  by  chills  and  a  high 
fever.  An  exploratory  puncture  at  the  le\'el  of  the  lowest  rib  revealed 
the  presence  of  pus,  which  was  subsequently^  found  to  contain  gono- 
cocci.  An  exploratory  incision  showed  the  condition  to  be  a  peri- 
nephritic  abscess.  Gonococci  were  again  demonstrated,  and  were  also 
found  in  the  connective  tissue.  Recovery  followed  the  operation. 
This  locality  is  rarely  attacked  by  the  gonococcus;  indeed,  many 
writers  assert  that  this  organism  never  invades  connective  tissue 
jM-imarily. 

GONORRHEA  OF  THE  NERVOUS  SYSTEM 

Only  in  rare  instances  does  the  gonococcus  produce  lesions  in  the 
nervous  system,  although  paragonorrheal  manifestations  are  more 
frequent.  The  etiology  is  not  definitely  clear.  Moltschanoff,'^  Kien- 
bock,"  and  others  believe  that  it  is  due  to  toxins.  IVIoltschanoff  in- 
jected killed  cultures  of  gonococci  into  animals.     In  these  cases  an 

'  Cumston,  C.  G.:  Univ.  Penn.  Med.  Mag.,  Phila.,  1899,  vol.  xi,  p.  504. 

'Young,  H.  H.:  The  Gonococcus:  A  Report  of  Successful  Cultivations.  Contribu- 
tions to  the  Science  of  Medicine,  Baltimore,  1900,  p.  704. 

'  Cabot,  F.:  Post.  Grad.,  New  York,  1906,  vol.  xxi,  p.  559. 

'  Ravogli,  A.:  Anier.  Jour.  Urology,  New  York,  1906,  vol.  ii,  p.  551. 

'  Denis:  Jour.  M&i.  de  Bru.v,  1907,  vol.  xii,  p.  44. 

"  StoyantchofT:  Amcr.  .Jour.  Urology,  New  York,  1909,  vol.  v,  p.  184. 

'  Kiister  and  Wagner:  Handbuch  der  Urologie,  vol.  ii,  p.  178. 

»  Waelsch:  Handb.  d.  Gcschlechtsk.,  Leipzig  and  Vienna,  1910,  vol.  i,  p.  815. 

'  \Madimirsky:  Dermal.  Zcitsch.,  vol.  x,  p.  320. 

">  Carlslaw:  Gla-sgow  Med.  Jour.,  June,  1893,  vol.  xxxix.  No.  6. 

"  Aronatam,  N.  E.:  Amer.  Jour.  Dcrmat.,  March,  1912,  p.  120. 

"  Dowd:   Med.  Kec,  New  York,  1898,  vol.  liii,  p.  937. 

"  Stojan-whoff  and  Rosenfeld:   Berlin.  Win.  Woch.,  July  25,  1898. 

"  Pollock,  C.  E.,  and  Harrison,  L.  W. :  Gonococcal  Infections,  London,  1912,  p.  177. 

"  Mortz,  B.:  Rev.  clin.  d'Urol.,  Paris,  1912,  vol.  i,  p.  124. 

'•  Miyata:  Folia  Urologie,  1910,  vol.  v.  No.  10. 

"  Molt-schanolT;    Munch,  mod.  \\'()chn.,  1899,  vol.  xlvi,  p.  1013. 

"  Kienbock:   Suininl.  klin.  \'<)rtrag(',  Leipzig,  1901,  No.  315. 


462  -  GONORRHEA   IN   WOMEN 

ascending  paralysis  resulted,  and  it  was  possible  to  demonstrate 
microscopic  lesions  in  the  spinal  cord  and  peripheral  nerves. 

Neuritis  and  Neuralgia. — In  1888  Charcot'  directed  attention 
to  this  condition.  jNIany  of  the  cases  described  have  been  associated 
with  articular  lesions,  and  for  this  reason  difficulty  usually  occurs 
in  determining  the  exact  etiology  of  the  condition,  as  it  is  necessary 
to  exclude  the  muscular  atrophy  and  other  symptoms  that  may 
result  from  an  arthritis  from  those  produced  by  the  direct  action  of  the 
gonococcus  or  its  toxins  upon  the  nerves.  Eulenberg"  reports  the 
histories  of  9  cases  of  gonorrheal  neuritis,  in  6  of  which  the  sciatic  was 
the  nerve  involved,  2  were  of  the  tibial,  and  1  in  the  radial  and 
median.  Barbellion^  has  also  reported  the  history  of  a  case  of 
scratica,  presumably  due  to  the  gonococcus.  "V^Hien  sciatica  is  present, 
bilateral  involvement  usually  occurs.  Lesser^  believes  that  cases  of 
sciatica,  especially  those  occurring  in  women  in  whom  no  etiologic 
factor  can  be  demonstrated,  are  often  caused  by  gonorrhea.  These 
cases  are  associated  with  gonorrhea  of  the  genital  tract,  usually  a 
urethritis.  They  tend  to  recur  with  subsequent  attacks  of  gonorrhea, 
and  the  onset  is  generally  sudden.  Campbell^  describes  a  form  of 
toxic  neuritis  that  frequently  accompanies  gonorrheal  urethritis,  in 
which  single  nerves  or  groups  of  nerves  are  affected.  The  condition 
is  most  commonly  noted  in  the  nerve  supply  of  the  extensors  of  the  foot. 

General  gonorrheal  neuritis,  unassociated  with  articular  lesions, 
is  of  extreme  rarity.  Kienbock"  has  collected  4  such  cases.  In  1905 
Bernhart^  recorded  the  history  of  a  case  of  paralysis  in  the  distribution 
of  the  musculocutaneous  nerve,  which  he  attributed  to  this  type  of  in- 
fection. No  arthritis  was  present.  Lorat-Jacob  and  Salomon^  relate 
the  history  of  a  case  of  lumbosacral  radiculitis.  No  gonococci  were 
found  in  the  spinal  fluid,  although  the  authors  believed  the  condi- 
tion to  be  due  to  this  variety  of  infection.  Cros^  has  collected  several 
cases  of  crural  and  lumbo-abdominal  neuralgia  which  he  thought  due 
to  gonorrhea.  Dieulafoy  has  seen  2  cases  of  intercostal  neuralgia 
which  he  believes  were  the  result  of  gonorrhea.     Gonorrheal  myelitis 

'  Charcot,  Jean-Martin :  Le5ons  du  Mardi  k  la  Salpetriere,  July  3,  1883. 

=  Eulenberg:   Deut.  med.  Wooh.,  1900,  vol.  xxvi,  p.  686. 

=  Barbellion,  G.:  Jour,  de  m6d.  de  Paris,  1912,  2d  S.,  vol.  xxiv,  p.  356. 

*  Lesser:  Quoted  by  Cole:  Osier's  Modern  Medicine,  Lea  Bros.,  Philadelphia  and  New 
York,  1907,  p.  113. 

^  Campbell,  J.:  Amer.  Jour.  Dermat.,  May,  1912,  p.  225. 

*  Kenbock:  Samml.  klin.  Vortrage,  Leipzig,  1901,  No.  315. 
'  Bernhart:  Berlin,  khn.  Woch.,  1905,  vol.  xiii,  p.  1097. 

8  Lorat-Jacob  and  Salomon:  Bull,  de  la  Soc.  M6d.  des  H6p.  de  Paris,  July  4, 1907,  p.  679. 
^Cros:    Quoted  by  Dieulafoy:   A  Text-book  of  Medicine  (translation),  1910,  vol.  ii, 
p.  2001. 


GONORRHEA    OF    THE    NERVOUS    SYSTEM  463 

of  the  diffuse  dorsolumbar  type  has  been  described.  The  cranial 
meninges  and  even  the  brain  itself  may  be  attacked  by  the  gonococcus. 
This,  however,  very  rarely  occurs.  Dieulafoy^  states  that  the  symp- 
toms may  be  of  four  distinct  types:  delirious,  maniacal,  meningitic, 
and  apoplectic.  In  the  two  last  the  prognosis  is  extremely  grave. 
As  early  as  1870  Politzer-  mentioned  a  case  in  which  purulent  con- 
junctivitis was  followed  by  meningitis.  Haushalter'  referred  to  a  case 
of  microcephalus  and  idiocy  which  he  ascribed  to  gonococci  passing 
from  an  inflamed  ej-e  to  the  meninges  and  brain  substance.  Fiir- 
bringer''  has  reported  the  history  of  an  interesting  case:  The  patient,  a 
laborer,  suffered  from  a  urethritis  and  more  or  less  severe  wandering 
pains  over  the  entire  body;  he  became  stuporous  and  partially 
unconscious.  Lumbar  puncture  evacuated  25  c.c.  of  partially  puru- 
lent, turbid  fluid,  which  contained  organisms  morphologically  similar 
to  the  gonococcus.  The  case  terminated  fatally,  and  at  autopsy 
the  pia  mater  and  spinal  cord  were  found  infiltrated  with  pus  which 
contained  similar  microorganisms.  Kienbock,°  Ware,^  Kankarovilsch,^ 
Glyn,'  Leyden,''  Sellenew,'"  and  Christmass"  have  reported  instances  of 
neuritis  believed  to  have  been  produced  by  the  gonococcus  or  its  toxins. 
In  most  cases  the  lesions  have  been  multiple. 

Diagnosis. — The  demonstration  of  the  gonococcus  in  lesions  of  the 
nervous  sj'stem  is  attended  by  much  difficulty,  and  manj'  of  the  re- 
corded cases  are  of  doubtful  etiology.  Thus,  in  1894  Barrie'-  collected 
25  cases,  in  only  a  very  few  of  which  was  the  chnical  diagnosis  confirmed 
by  autopsy  findings.  In  none  of  these  cases  were  gonococci  cultivated 
from  the  lesions  in  the  nervous  system.  Coincident  neurologic  condi- 
tions must  be  excluded. 

Neuroses. — Neuroses  are  more  frequent  in  men  than  in  women, 
and  usually  manifest  themselves  during  the  course  of  a  posterior 
urethritis ;  they  are  paragonorrheal  in  type.  The  symptoms  may  vary 
from  a  slight  melancholia  to  severe  mental  disturbances.  Among 
women,  neuroses  are  more  frequent  during  pregnancy  or  the  puer- 

•  Dieulafoy:  A  Text-book  of  Medicine,  1910,  vol.  ii,  p.  2001. 

2  Politzer:  Jahrb.  f.  Ivinderheilk.,  1870,  p.  335. 

'  Ilaushalter;  Quoted  by  S.  Stephenson:  Ophthalmia  Nponatoriim,  London,  1907, 
p.  U2. 

'  Furbringer:   Deut.  med.  Woch.,  1899. 

'  Kicnbock:  Volkmann's  Samml.  klin.  Vortriige,  No.  92. 

"  Ware,  M.  F.:  Amcr.  .Jour.  Med.  Sci.,  July,  1901. 

'  Kankarovilsch:   Vratch,  1901,  p.  13-tG.  »Glyn:   Lancet,  September  27,  1902. 

»  Leyden:  Zeit.  f.  klin.  Med.,  1892,  vol.  x.xi. 

'» .Sellenew:  Monats.  f.  Urologie,  1902,  No.  10,  p.  590. 

"  C'hristma.ss:  Annal.  de  I'lnst.  Pasteur,  vol.  xi.  No.  7. 

'■  Harrie:  Quoted  by  Cole:  Osier's  Modern  Medicine,  Pliihidclpliia  and  New  York, 
1907,  p.  113. 


464  GONORRHEA    IN   WOMEN 

perium,  and  in  married  women  than  in  the  single.  No  doubt  frequent 
local  treatment  and,  in  many,  the  fear  of  a  possible  operation,  are 
contributing  factors.  Long-continued  pain  and  self-reproach  for  an 
illicit  intercourse  are  also  predisposing  causes.  Bossi'  believes  that 
much  hysteria  and  many  neuropathic  conditions  and  psychopathies, 
with  their  resulting  suicides  and  crimes,  are  dependent  upon  chronic 
lesions  of  the  genital  organs,  especially  when  of  infectious  origin.  He 
cites  many  cases  in  which  hysteria,  Graves'  disease,  mental  alienation, 
kleptomania,  suicide,  and  murder  have  resulted  in  individuals  in  whom 
it  was  possible  to  demonstrate  the  presence  of  chronic  genital  lesions. 
Many  of  these  cases  recovered  after  a  course  of  careful  gynecologic 
treatment.  Bossi  believes  that  every  insane  woman  should  be  care- 
fully examined,  and  if  gynecologic  lesions  are  found,  these  should  re- 
ceive appropriate  treatment.  Bossi  advocates  an  active  propaganda 
among  physicians  and  the  public  to  teach  the  undoubted  effect  of  the 
condition  of  the  genital  organs  on  the  nervous  and  mental  systems. 
Ortenau-  and  Schultze-'  agree  with  Bossi's  conclusions.  Manton^ 
doubts  whether  pelvic  disorders  ever  cause  insanity,  but  states  that 
certain  conditions,  by  acting  as  foci  of  irritation,  tend  to  prolong  the 
insane  condition  and  add  more  or  less  to  its  severity.  Guicciardi  and 
Leoni'^  and  Taussig'^  are  of  a  similar  opinion.  The  last-named  author 
states  that  there  are  three  facts  that  point  to  some  sort  of  relationship 
existing  between  gjaiecologic  disease  and  manic-depressive  insanity. 
These  are  the  decidedly  greater  frequency  of  gynecologic  disease  in 
the  insane, — 74  per  cent.,  as  compared  with  the  average  47  per  cent., — 
the  large  proportion  of  chronic  inflammatory  conditiolis  in  the  insane, 
and  the  proportionately  large  percentage  of  mental  recoveries  after 
gynecologic  operations  performed  on  women  having  manic-depressive 
insanity.  Taussig"  concludes  that  in  manic-depressive  insanity  every 
patient  should  be  subjected  to  a  gynecologic  examination,  and  that 
when  a  definite  lesion  is  found,  this  should  be  corrected.  Neuroses 
the  result  of  gonorrhea  have  also  been  described  by  Orlipski.^  The 
author  beUeves  that  Bossi's  views  are  extreme,  and  that  great  caution 
should  be  exercised  before  attributing  insanity  to  pelvic  inflammatory 
lesions.  Chronic  suffering  of  any  kind  is  no  doubt  a  predisposing 
cause  in  many  cases. 

'  Bossi:  Rev.  Mens,  de  Gyn.,  d'Obst.,  et  de  Psed.,  November,  1911. 

=  Ortenau,  G.:  Munch,  med.  Woch.,  October  29,  1912. 

'  Schultze:  Quoted  by  Taussig,  F.  J.:  Jour.  Amer.  Med.  Assoc,  August  31, 1912,  p.  713. 

"  Manton:   Ibid.,  p.  715.  '  Guicciardi  and  Leoni:  Annali  di  Ostetriea,  .July,  1912. 

"  Taussig,  F.  J.:  .Jour.  Amer.  Med.  Assoc,  August  31,  1912,  p.  713. 

'Taussig:  hoc.  cil.  ^Qrlipski:    Alleg.  med.  Central- Zeitung,  1912,  No.  43. 


SUPPURATIVE  MYOSITIS  AND  GONORRHEAL  SUBCUTANEOUS  ABSCESS       465 
GONORRHEAL  PAROTIDITIS 

Dennis'  reports  a  case  of  parotiditis  probablj^  gonorrheal  in  origin. 
The  patient  was  a  woman  twenty-eight  years  of  age.  Symptoms  of 
pelvic  peritonitis  had  been  present  for  some  time.  No  attempt  was 
made  to  demonstrate  gonococci  in  the  genito-urinary  tract.  Twelve 
days  after  the  appearance  of  an  arthritis  the  right  jaarotid  gland  became 
swollen  and  tender;  a  few  days  later  the  left  gland  also  became  in- 
volved. The  skin  over  the  gland  was  red,  swollen,  and  shiny.  Later, 
fluctuation  could  be  elicited.  The  gland  was  incised  and  drained. 
The  pus  obtained  contained  numerous  diplococci.  No  other  micro- 
organism could  be  detected.  These  cocci  were  morphologically  similar 
to  the  gonococcus.  No  cultures  were  made,  and  consequently  the 
possibilit}'  of  the  infection  having  been  due  to  the  ]Micrococcus  catar- 
rhalis,  an  organism  morphologically  and  tinctorially  similar  to  the 
gonococcus,  and  a  frequent  inhabitant  of  the  mouth,  cannot  be  ex- 
cluded. Powers-  records  the  history  of  a  case  in  which  the  entire 
ui)per  extremity  on  one  side  was  involved.  A  little  later  a  parotiditis 
developed.  Gonococci  and  staphylococci  were  demonstrated  in  the 
discharge  from  the  parotid  gland,  from  the  neck,  and  from  the  chest. 
The  case  is  not  described  in  detail,  nor  has  it  been  possible  to  trace 
the  reference. 

GONORRHEAL  OTITIS 
Reinhard-'  has  reported  the  history  of  a  case  of  this  condition  that 
occurred  in  a  child.  Gonorrheal  vulvovaginitis  was  also  present. 
The  clinical  symptoms  of  the  otitis  differed  in  no  respect  from  those 
usually  encountered  in  cases  of  otitis  due  to  the  ordinary  pyogenic 
microcirganism.  In  Reinhard's  case  gonococci  were  demonstrated  by 
both  smear  and  culture  in  the  dischaige.  The  nose  and  pharynx  were 
not  involved.  The  condition  yielded  readily  to  treatment,  which 
consisted  in  irrigations  with  a  weak  antiseptic  solution. 


SUPPURATIVE  MYOSITIS   AND  SUBCUTANEOUS   ABSCESS   OF  GONORRHEAL 

ORIGIN 

For  many  years  it  was  thought  that  the  gonococcus  could  nut  pvu- 

duce  suppuration  in  connective  tissue.     This  was  due  largely  to  the 

experiments  of  Wertheim'  and  Steinschneidcr.^     The  former  injected 

'  Dcnni.s,  \V.  A.:  St.  Paul  Med.  Jour.,  1911,  vol.  xiii,  p.  l.s:$. 

■  Powers,  C.  A.;   Quoted  by  Campbell,  W.  F.:   New  '^'ork  Meil.  .Imii-.,  February  22, 
li)()S.  p.  :J5C. 

'  Reinhard:  Abst.  in  .\mer.  Jour.  Urology,  1908,  vol.  iv,  p.  Uti. 
'  VVcrlheim:  .■Xrch.  f.  Oyn.,  Berlin,  1S92,  vol.  .\lii,  p.  00. 
'.Stein.schneider:   Berlin,  klin.  Woeh.,  1893,  p.  729. 


466  GONORRHEA    IN    WOMEN 

a  pure  culture  of  gonococci  into  the  subcutaneous  tissue  of  two  men. 
The  only  result  was  a  moderate  degree  of  redness  and  induration  over 
the  site  of  inoculation,  which  disappeared  in  three  days.  Under 
similar  cu'cumstances  the  latter  authority,  even  when  employing  large 
amounts  of  pure  cultures,  failed  to  produce  any  reaction  whatever. 

In  neglected  or  unusually  severe  cases  of  suppurative  bone  or  joint 
lesions  extension  to  the  adjacent  muscles  is  not  uncommon,  and  has 
been  commented  upon  by  Decousser,i  Horwitz,-  Lang  and  Paltauf,' 
Jundell,*  Young,''  and  others.  Abscesses  occurring  in  muscles  in 
conjunction  with  septicemia  are  less  frequent. 

The  following  writers  have  recorded  the  histories  of  cases  in  which 
intramuscular  abscesses  of  gonococcal  origin  have  been  present: 
Harris  and  HaskelP  have  recorded  a  case  in  which  a  suppurative 
process  was  present  in  the  gastrocnemius  and  soleus  muscles;  Bujivid,'' 
Bloodgood  and  Young,^  Wynn,'  Cassel,^"  Strong,^i  Kienbock,^-  Ware,^' 
Lang  and  Paltauf.^^  The  last  two  authors  were  the  first  to  demonstrate 
gonococci  in  pure  culture  from  a  subcutaneous  abscess,  but  credit 
is  due  to  Bujivid^^  for  the  similar  demonstration  in  intramuscular 
abscesses  not  associated  with  tendon-sheath  infection.  In  Horwitz's^^ 
and  Lang  and  Paltauf's"  cases  the  abscess  occurred  upon  the  dorsum 
of  the  hand  in  connection  with  a  tenosynovitis.  Jundell's^^  case  was 
one  of  a  large  subcutaneous  abscess  in  the  calf  of  the  leg  in  connection 
with  a  tenosynovitis  of  the  tibialis  posticus  muscle.  The  abscess 
appeared  in  the  third  week  of  the  gonorrhea,  and  was  cured  by  free 

'  Decousser:  These  de  Paris,  1905. 

2  Horwitz:  Wien.  klin.  Woch.,  1893,  vol.  vi,  p.  69. 

^  Lang  and  Paltauf :  Arch.  f.  Dermat.  u.  Syph.,  Vienna,  1903,  vol.  xxv,  p.  330. 

'  Jundell:  Ai-ch.  f.  Dermat.  u.  Syph.,  Vienna,  1897,  vol.  xx,\ix,  p.  75. 

'  Young,  H.  H. :  Contributions  to  the  Science  of  Medicine,  Baltimore,  1900,  p.  677. 

«  Harris  and  Haskell:  Johns  Hopkins  Hospital  Bull.,  1904,  vol.  xv,  p.  395. 

'  Bujivid:  Cent.  f.  Bakt.,  1895,  vol.  xviii,  p.  435;  also  Arch.  f.  Dermat.  u.  Syph.,  ^'ienna, 
vol.  x.xxviii. 

8  Bloodgood  and  Young:  Quoted  by  Thayer  and  Lazoar,  J.  S.:  Jour.  E.xper.  INIed., 
1899,  vol.  iv,  p.  95. 

»  Wynn:  Lancet,  February  11,  190.5,  p.  352. 

'"  Cassel:  Vcrein  f.  innere  Medizin,  Berlin,  June  8,  1903. 

"Strong:  Quoted  by  Campbell,  W.  F.:  New  York  Med.  Jour.,  February  22,  1908, 
p.  356. 

'^  Kienbock:  Volkmann's  Samml.  klin.  Vortrage,  No.  92. 

"  Ware,  M.  F.:  Amer.  Jour.  Med.  Sci.,  July,  1901. 

"  Lang  and  Paltauf:  Arch.  f.  Dermat.  u.  Syph.,  Vienna,  1903,  vol.  xxv,  p.  330. 

"5  Bujivid:  Cent.  f.  Bakt.,  1895,  vol.  xviii,  p.  435;  also  Arch.  f.  Dermat.  u.  Syph., 
Vienna,  vol.  xxxviii. 

"  Horwitz:  Wien.  klin.  Woch.,  1893,  vol.  vi,  p.  59. 

"  Lang  and  Paltauf:  Aich.  f.  Dermat.  u.  Syph.,  Vienna,  1903,  vol.  xxv,  p.  330. 

'» Jundell:  Loc.  cil.,  1897,  vol.  x\-xix,  p.  175. 


LOCAL    WOUND    INFECTION    BY    GONOCOCCI  467 

incisions  and  drainage.  Bujivid'  records  the  history  of  a  man  suffering 
from  a  urethritis  in  whom  four  abscesses  appeared  one  week  after  a 
catheterization.  One  abscess  was  in  front  of  the  left  elbow,  one  in  the 
right  popliteal  space,  one  over  the  right  external  malleolus,  and  one  on 
the  inner  side  of  the  left  leg.  Bujivid  believes  the  abscesses  to  have 
been  intramuscular,  but  this  was  not  positively  proved.  Young-  reports 
a  peri-urethral  abscess,  a  large  peritoneal  abscess,  a  gonococcal  infection 
of  an  arthrectomy  wound  in  the  knee,  with  superficial  abscesses  in  the 
region  of  the  incisions,  a  subcutaneous  abscess  on  the  dorsum  of  the 
hand,  an  abscess  and  fistula  of  the  perineum  and  scrotum,  all  occurring 
in  men.  The  etiology  of  the  lesions  in  all  but  one  case  was  proved  by 
smears  and  cultures;  in  one  case  the  cultures  were  negative.  Ste- 
phenson' records  a  remarkable  case  of  gonorrheal  septicemia  secondary 
to  an  eye  lesion  in  an  infant,  in  which  numerous  abscesses,  both  sub- 
cutaneous and  intramammary,  were  present,  and  from  the  pus  of 
which  gonococci  were  identified  by  staining  methods.  Abscesses  the 
result  of  the  gonococcus  do  not  differ  from  those  produced  by  other 
pj'ogenic  microorganisms.  The  concomitant  symptoms  of  septicemia 
are  usually  present.  Cassel's*  case  occurred  in  an  infant.  One  of  the 
muscles  in  the  back  was  the  part  attacked.  Ophthalmia  was  also 
present.  Gonococci  in  pure  culture  were  demonstrated  from  both 
lesions.  In  one  of  Wynn's*  cases  the  abscesses  were  of  large  size  and 
bilateral,  both  calves  being  involved.  ]Mixed  infection  is  frequent. 
Cases  of  cellulitis  in  areas  other  than  the  pelvis  have  been  recorded 
by  Hansen"  and  Almkvist.^  In  the  former's  case  a  hard,  indurated 
swelling  appeared  on  the  sternimi,  which  subsequently  became  fluctu- 
ant, and  finally  broke  down,  and  from  the  pus  of  which  gonococci  were 
demonstrated.  In  Almkvist's  case  bilateral  areas  of  celluhtis  ap- 
peared on  the  inner  side  of  the  tarsus;  these  finally  suppurated  and 
gonococci  were  identified  in  the  pus. 


WOUND  INFECTION  BY  GONOCOCCI 
This  is  comparatively  seldom  encountered,  but  occasionally  fol- 
lows arthrotomy,  as  in  the  cases  recorded  by  Meyei-*  and  Young.' 

'  Hujivid:    Cent.  f.  Bakt.,  1895,  vol.  xviii,  p.  435;    also  Arch.  f.  Dcrmat.  u.  Syph., 
Vionnu,  vol.  xxxviii. 

•  Young,  II.  H.:  Contributions  to  the  Science  of  Medicine,  Baltimore,  1900,  p.  077. 

^  .'Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  H3. 

'  Ca.ssel:  Verein  f.  inncre  Mcdizin,  Berlin,  June  8,  1903. 

'  Wynn:  Lancet,  February  11,  190.5,  p.  352.         '  Hansen,  C.  T.:   Ocnniit.  Zeit.,  1910. 

'  .\lmkvist,  J.:  Arch.  f.  Dermat.  u.  Syph.,  1899,  vol.  xlix,  p.  Ki.'J. 

"  Meyer,  F.:  Deut.  nied.  Woch.,  1903,  vol.  x.\ix. 

»  Voiini;:  -lohns  Hopkins  Hosp  Hi'i)(>rls,  Balliiiiore,  I'.IOO,  vol.  ix,  p.  (177. 


468  GONORRHEA   IN   WOMEN 

Baginsky'  has  reported  the  history  of  a  case  in  which  the  umbilical 
cord  was  infected  by  the  gonococcus.  Welander-  mentions  2  cases  of 
orbital  infection  by  the  gonococcus  following  enucleation  of  the  eyes. 
Both  patients  were  males  and  were  the  incumbents  of  uncured  urethral 
gonorrhea.  Welander  believes  that  the  infection  resulted  from  pro- 
tective eye-glasses  which  were  worn  after  the  enucleation,  and  that 
the  eye-glasses  were  contaminated  by  the  patients  while  attempting  to 
clean  them  with  infected  fingers. 

Emery  and  Sabatier^  report  the  history  of  a  case  of  a  nurse  who 
accidentally  ran  a  splinter  of  wood  into  her  finger,  and  who,  a  few 
hours  later,  dressed  a  case  of  bartholinitis.  Within  twelve  hours  the 
finger  began  to  pain,  and  in  spite  of  poultices,  etc.,  pus  formed.  The 
abscess  was  opened  on  the  fifth  day.  Gonococci  were  demonstrated 
in  the  pus.  The  condition  was  strictly  local  and  the  source  of  the 
infection  undoubted.  Sarferf  found  the  gonococcus  the  infecting 
agent  in  a  mammary  abscess  occurring  during  the  puerperium. 

That  local  wound  infection  is  of  rare  occurrence  is  proved  by  the 
relative  infrequency  in  which  infection  occurs  when  operating  for 
gonorrheal  lesions,  or  when  performing  plastic  operations  upon  women 
known  to  be  suffering  from  this  disease.  West^  reports  an  interesting 
case  of  this  kind  in  which  the  abdominal  wound  broke  down  after  a 
bilateral  salpingectomy  for  gonorrheal  pus-tubes.  Cionococci  were 
recovered  in  the  pus  from  the  wound  for  some  time  subsequent  to 
the  operation,  but  disappeared  after  a  thorough  irrigation  of  the  wound 
with  25  per  cent,  argyrol.  The  wound  then  healed  rapidly  and  com- 
plete recovery  followed,  v.  Leyden*  found  gonococci  in  a  myocardial 
abscess  and  in  vegetations  on  the  valves.  The  organisms  were  identi- 
fied by  their  morphology  and  staining  properties. 

'  Baginskv:  Quoted  bj-  Cole:  Osier's  ISIodern  Medicine,  Philadelphia  and  New  York, 
1907,  p.  92. 

'  Welander:  Quoted  by  Ledermann,  R.:  Amer.  Jour.  Dermat.,  November,  1910,  p.  .520. 

'  Emery  and  Sabatier:  La  Clinique,  November  10,  1909. 

"  Sarfert:  Deut.  med.  Woch.,  1894,  No.  S. 

^  West:  The  Post-Graduate,  April,  1912,  p.  275. 

«  V.  Leyden:  Deut.  med.  Woch.,  1893,  p.  909. 


CHAPTER  XX 

GONORRHEAL  THERAPY 

DRUGS  EMPLOYED  IN  THE  LOCAL  TREATMENT  OF  GONORRHEA 
The  local  treatment  of  gonorrhea  is  one  of  the  most  difficult  prob- 
lems in  modern  medicine,  and  it  is  because  of  the  unsatisfactory  results 
often  obtained  that  many  female  gonorrheics  ultimately  become 
surgical  cases.  In  order  intelligently  to  institute  the  proper  local 
treatment  of  gonorrhea  a  thorough  knowledge  of  the  pathology  of  the 
lesions  to  be  dealt  with,  the  stage  of  the  disease,  and  the  individual 
peculiarities  of  the  patient,  as  well  as  her  social  standing  and  morale, 
is  necessary.  The  gonococcus  is  an  organism  pecuharly  susceptible 
to  germicides,  and  when  encountered  outside  of  the  human  body, 
is  comparatively  easily  destroyed  by  disinfectants  in  general  and  by 
variations  in  heat  and  moisture;  once,  however,  it  becomes  established 
in  the  genital  tract  or  in  other-  locations  favorable  for  its  growth,  it 
is  most  difficult  to  eradicate,  and  exhibits  a  clinical  chronicity  and  a 
tenacitj'  of  life  most  at  variance  with  its  bacteriologic  properties  as 
manifested  in  culture-media.  These  peculiarities  are  due  not  to  the 
fact  that  the  gonococcus  is  so  much  more  tenacious  of  life  in  man,  but 
that  the  localities  attacked  are  so  constructed  anatomically  as  to 
preclude  the  germicides  reaching  the  infecting  organisms.  It  is  well 
established  that  gonococci,  when  first  deposited  upon  a  mucous  mem- 
brane, can  be  readily  killed  or  wa.shed  away,  provided  such  treatment 
is  employed  before  the  microorganism  has  penetrated  below  the  surface 
epithelium.  The  almost  marvelous  results  obtained  from  the  prophy- 
lactic treatment  of  gonorrhea  as  carried  out  aboard  many  of  the  ships 
of  the  I'nited  States  navy,  and  the  efficiency  of  the  Cred6  prophylactic 
treatment  of  oi)hthalmia  neonatorum,  bear  out  this  assertion.  When, 
however,  a  few  hours  or  days  have  been  permitted  to  elapse  and  the 
gonococcus  has  penetrated  the  depths  of  the  mucosa,  irrigations  are  of 
much  less  value,  for  althf)ugh  the  micr()(')rganisnis  on  the  surface  are 
doubtless  destroyed,  vast  numbers  (>scape  the  action  of  the  germicide. 
Janet'  riglitly  believes  that  this  constant  reinfection  from  areas  not 
reached  by  the  applications  is  the  I'hicf  cause  for  the  resistance  to 
treatment  exhibited  l)y  gonorrhea  in  l)oth  men  and  woiiieii. 

Experimental   research   has   amply   demonstrated    that    althoiigli 

'  .laiict,  J.:  Jour.  d'T'rol.,  Paris,  Xovt'iiilicr.  1!)12,  vol.  ii.  No.  .">. 
4*>il 


470  GONORRHEA    IX    WOMEN 

certain  germicides  penetrate  the  tissues  to  some  depth,  the  presence  of 
organic  matter  or  of  various  other  constituents  that  are  always  present 
in  the  mucosa  tends  to  effect  a  chemical  change  in  the  germicide  and 
thus  greatly  or  entirely  nuUify  their  effects.  It  is  this  change  and  the 
fact  that  gonococci  are  prone  to  inhabit  the  depths  of  the  mucous 
glands,  where  they  cannot  be  reached  by  the  chemical  agent,  that 
account  for  the  resistance  of  gonorrhea  to  local  treatment.  All 
clinicians  know  that  strong  caustics,  by  their  irritant  and  destructive 
action,  generally  favor,  rather  than  retard,  the  course  of  a  gonorrhea. 
Hence  the  three  requirements  that  a  gonococcid  to  be  employed  in 
the  local  treatment  of  this  disease  should  possess  are,  therefore,  a 
destructive  action  on  the  gonococcus  and  on  other  microorganisms, 
such  as  the  staphylococcus,  that  may  be  present  in  mixed  infections; 
ability  to  penetrate  the  tissue  without  losing  its  germicidal  properties, 
and  a  non-irritant  action.  No  germicide  as  yet  known  entirely  ful- 
fils these  requirements.  The  vast  number  of  drugs  in  various  strengths 
and  combinations  that  have  been  employed  in  the  treatment  of  gonor- 
rhea bear  evidence  that  the  ideal  gonococcid  has  not  yet  been  dis- 
covered. 

Marshall  and  Neave^  have  shown  conclusively,  by  careful  lab- 
oratory investigations,  that  the  amount  of  silver  that  a  compound 
may  contain  is  no  criterion  of  its  bactericidal  power.  This  fact  has 
also  been  amply  proved  clinically,  and  is  of  importance  when  consider- 
ing the  employment  of  the  various  silver  preparations  now  on  the 
market. 

Many  methods  have  been  employed  for  testing  the  germicidal 
properties  of  different  preparations.  As  early  as  1881  Robert  Koch^ 
undertook  this  difficult  task.  What  is  known  as  the  Koch  thread 
method  consisted  in  saturating  a  silk  thread  in  an  emulsion  of  the 
microorganism,  allowing  these  threads  to  dry,  and  subjecting  them  to 
the  action  of  various  chemical  agents.  The  disadvantages  of  this 
method  are  that  the  organisms  are  dried,  which  in  itself  tends  to  destroy 
the  gonococcus,  and  that  the  disinfectants  are  carried  over  with  or  in  the 
thread  to  the  culture-medium.  In  1897  Kronig  and  Paul'  suggested 
the  "garnet"  method..  This  consisted  in  anointing  the  surface  of  a 
number  of  garnets  of  equal  size  with  an  emulsion  of  the  microorganisms, 
drying  and  subsequently  exposing  them  to  the  action  of  disinfectants, 
and  then  testing  them  in  a  culture-medium  for  the  presence  of  the 
original  microorganism.     A   source  of  error  in  this  method  lies  in 

'  Marshall,  C.  R.,  and  Neave,  E.  F.  M.:  Brit.  Med.  Jour.,  August  IS,  1906,  p.  359. 
=  Koch,  K.:  Mittheil.  a.  d.  kaiserl.  Gesundheitsamte,  1881,  vol.  i. 
^  Kronig  and  Paul:  Zeit.  f.  Hygiene,  1897,  vol.  xxv,  p.  1. 


GONORRHEAL    THERAPY  471 

the  fact  that  in  the  washing  of  the  garnets  the  organisms  as  well  as 
the  disinfectant  are  likely  to  be  washed  away.  Gruber/  Seligmann,^ 
Schumburg.'  and  Proskauer^  have  all  warned  against  accepting  re- 
sults formulated  upon  methods  in  which  this  possibilitj-  is  not  excluded. 
The  danger  of  carrying  over  mercuric  salts  is  verj'  great,  and  it  is 
probably  due  to  a  lack  of  knowledge  regarding  this  point  that  mercury 
bichlorid  now  holds  its  present  high  place  in  the  list  of  antiseptics. 
To  guard  against  this  possibility  Cliick  and  Martin^  suggest  that  the 
mercuric  salts  be  neutraUzed  with  a  sulphid  solution.  These  authors 
have  shown  that  organisms  subjected  to  the  action  of  mercuric  salts 
and  subsequently  washed  free  of  the  disinfectant  may  not  grow'  if 
planted  directly  into  broth,  but  that  they  are  not  necessarily  damaged 
irretrievably,  and  that,  if  treated  with  a  sulphid  solution,  a  certain 
proportion  can  be  resuscitated.  The  same  authorities  have  demon- 
strated that  a  virulent  strain  of  an}'  particular  species  is  generally 
somewhat  more  difficult  to  kill  than  a  non-virulent  strain.  In  1903 
Rideal  and  Walker^  recommended  the  use  of  the  drop  method,  which 
has  since  been  used,  with  occasional  slight  modifications,  by  Firth 
and  Macfadyen,^  Post  and  Nicoll,*  Chick  and  Martin,'  Clark  and 
Wylie,^"  Derb}','^  and  many  others.  Post  and  NicolU-  employed  the 
drop  method  as  follows:  One-half  a  cubic  centimeter  of  the  solution 
to  be  tested  was  placed  in  a  small  sterile  test-tube.  Into  this  was 
placed  one  platinum  loopful  of  an  enmlsion  (in  culture  broth)  of  a 
twentj'-four-hour  culture,  in  blood-agar  slant,  of  the  organism  used. 
After  one  minute,  ten  minutes,  thirty  minutes,  and  twenty  hours  a 
loopful  of  the  contaminated  test  solution  was  thoroughly  mixed  in  a 
tube  of  blood-agar  and  plated  in  ordinary  sterile  Petri  dishes.  These 
were  then  incubated  at  37°  C,  and  observed  after  twenty-four,  forty- 
eight,  and  seventy-two  hours.  In  the  case  of  large  numbers  of  colonies 
the  figures  given  in  Post  and  Nicoll's  tables  are  approximate,  and  if 

■  Gruber:  Cent,  f  Bakt.,  1891,  1.  Abt.,  vol.  xi,  1892,  p.  115. 

'.Soligmann:  Her.  v.  d.  XIV.  Internal.  Kong.  f.  Hyg.  u.  Dem.,  Berlin,  1907,  vol. 
ii,  p.  '.i7'3. 

'Schumburg:    Deut.  med.  VVoch.,  Berlin,  February,  1912,  vol.  x.x.vviii,  No.  9. 

•  Proskauer:  Ber.  v.  d.  XIV.  Internal.  Kong.  f.  Hyg.  u.  Dem.,  Berlin,  1907,  vol.  il, 
p.  97:i. 

''  Chick.  II.,  anil  Martin,  C.  J.:  Jour,  of  Hygiene,  1908,  vol.  viii,  p.  668. 

'■  Rideal,  .S.,  and  Walker,  J.  I.  A.:  Jour.  Roy.  San.  Inst.,  London,  1903,  vol.  x,\iv,  p.  424. 

'  Firth  and  Macfadyen:   Jour.  Roy.  San.  Inst.,  1906,  vol.  xxvii,  p.  17. 

»  Post,  \V.  E.,  and  NicoU,  H.  K.:  Jour.  Amer.  Med.  Assoc.,  November  5,  1910,  p.  1635. 

»  Chick,  H.,  anil  Martin,  C.  J.:  Jour,  of  Hygiene,  1908,  vol.  viii,  p.  6.54. 

'"  Clark,  J.  B.,  and  Wylie,  L.  A.:  Jour.  Amer.  Med.  Assoc.,  July  29,  1911. 

"  Derby,  G.  S.:  Trans.  Amer.  Ophthal.  Soc,  1906,  vol.  xi,  pari  i,  p.  21. 

"  Po.st,  W.  E.,  and  Nicoll,  H.  K.:  Jour.  Amer.  Med.  Assoc,  November  5,  1910,  p.  1035. 


472  GONORRHEA    IN    WOMEN 

the  number  of  the  colonies  was  too  great  to  permit  of  an  approximate 
estimation,  the  sign  of  infinity  (co )  was  used.  The  organisms  tested 
by  Post  and  NicoU  were  the  gonococcus,  streptococcus,  pneumococcus, 
and  typhoid  bacilhis.  The  results  relating  to  the  gonococcus  obtained 
by  these  authors  are  shown  by  the  following  tables.  The  strain  of 
gonococci  utilized  was  isolated  from  a  urethral  discharge: 

SOLUTIONS  OF  THE  SILVER  SALTS 
Xrunbcr  of  Colonies  in  One  Loopful  of  Test  Gonococcal  Solution  After: 

Solution                                                              1  Min.                10  Min.  30  Mix.  20  Hr3. 

Silver  nitrate,  1  per  cent 0                       0  0  0 

1:1000 0                      0  0  0 

1:5001) 0                      0  0  0 

"          "       1:  10,000 100                      0  0  0 

Argyrol,  50  per  cent 3000                 3000  2000  0 

10  per  cent 2000                2000  0  0 

Protargol,  10  per  cent 200                      0  0  0 

The  superiority  of  silver  nitrate  over  both  argyrol  and  protargol  is 
manifest. 

MERCURY  SOLUTIONS 
Xumher  of  Colonies  in  One  Loopful  of  Test  Gonococcal  Solution  After: 
Solution  1  Mis.  10  Mis.  30  MiN.  20  Hrs. 

Bichlorid  1 :  500 3000  20  1  0 

(From  Bernay's  tablets) 

Bic'lilorid,  1 :  2000 4000  3000  200  0 

1:10,000 .,  4000  500  25  0 

^-  .  .  ' 

Mercury  biniodid  .    1        1 

Potas.sium  iodid .1         j 

Sodium  bicarbonate  .   20      '.      0  0  0  0 

Water 1000  | 

(P.  D.  &  Co.  germicidal  di.scs.j  J 

^- 

Mercury  biniodid ,  11 

Potassium  iodid .  .  In                    n                    n                  n 

Sodium  bicarbonate  20             "                     "                     "                   " 

Water ,   2000  J 

^■ 

Mercury  biniodid ,1         ] 

Potassium  iodid I         I  ^ 

Sodium  bicarbonate 20  =^  °°  °°  ° 

Water 5000  J 

These  tests  show  that  the  action  of  mercury  is  slow,  but  effective, 
even  in  high  dilutions,  and  demonstrate  the  futility  of  the  ordinary 
mercuric  salts  as  generally  employed  in  antisepsis. 


GONORRHEAL    THERAPY 


473 


SOLUTION  OF  THE  PHEXOLS 

Xumber  of  Cciloiiics  in  One  Loopful  of  Test  Gonococcnl  Sulntion  After: 
Solution  1  Mix.  10  Mis.  30  Mis.  20  Hsa. 

Creolin,  100  per  cent.  0  0  0  0 

1  per  cent. .  2.")  0  0  0 

Creolin,  75  per  cent.    \ 
Glycerin,  25  per  cent. 

Kreso,  100  per  cent.  

■'      5  per  cent.  

"       1  per  cent.  , 

••       1:1000 


Kre.so,  50  per  cent.      \ 
(.ilycerin,  50  per  cent.  ^ 

Chinosol,  25  per  cent. 
"        0.4  per  cent. 
1:10,000.. 

Chinosol,  6  per  cent. 
Glycerin,  13  per  cent. 

Lj'sol,  100  per  cent 

"      1.5  per  cent. . 

"      1:1000 

Trikresol,  1  per  cent. 

"        0.3  per  cent 
Phenol,  5  per  cent. 
"         1  per  cent. 
1:1000 

Phenol,  50  per  cent. 
Glycerin,  50  per  cent. 

^.   Phenol 

Zinc  .siilpluitc 

(ilvceriii 

Water 


0 


0 


.  1  fir. 
.2  dr. 


0 


0 


0 

0 

0 

0 

0 

'  0 

0 

0 

0 

0 

0 

0 

5000 

4000 

2000 

300 

2000 

0 

0 

0 

(iOOO 

6000 

4000 

3000 

5000 

5000 

3000 

3000 

0 

0 

0 

0 

0 

0 

0 

0 

.-)()() 

1000 

1000 

50 

0 

0 

0 

10 

2000 

2000 

1000 

50 

0 

0 

0 

0 

4000 

.■)00 

0 

0 

til  Kill 

liDIII) 

4000 

3000 

In  this  connection  it  Is  worth  mcntioiiiiig  that  kreso  may  be 
bought  for  about  eighty  cents  a  gallon,  whereas  the  same  amount  of 
lysol  costs  between  three  and  four  dollars.  The  former  is  not,  however, 
so  refined  nor  so  easily  miscible  with  water  as  the  latter,  but  it  is  more 
effective. 


SOLUTIONS  OF  lODIN 
Xumbcr  of  Cohnies  in  One  Loopful  of  Teal  (lonocnccal  Solution  After: 

SOLDTIOS  1  Mis.  Id  Mrs.  W  .Mis.  20  Hli8. 

^.  lodin 11 

IWsiuni  io.li.1  .11      0                    0                      0                    0 

\\ater 100 

(Senn's  solution  i  J 

lodin .      11 

l'ot!i.s.siuin  iodid  .      1  ;■      0  0  0  0 

Water 400  J 

Tincture  iodin  .0  0  0  0 

These  solutions  killed  all  the  organisms  of  the  four  varieties  tested. 


474  GONORRHEA   IN  WOMEN 

SOLUTIONS  OF  LIQUOR  FORMALDEHYDI 

A'umber  of  Colonies  in  One  Loopful  of  Test  Gonococcal  Solution  After: 

Solution                                                      1  Mm.               10  Min.                30  Min.  20  Has. 

Liquor  formaldehydi  (U.  S.  P.) 0                       0                       0  0 

Liquor  formaldehydi,  1  per  cent 4000                2000                1000  0 

1:1000 6000                6000                6000  0 

1:10,000 4000                4000                5000  2000 

„,  "    ■     ne     "        f  ^  ^^''  '^'""''  \ 10000              10000                4000  0 

Glycerin,  98  per  cent.  J 

SOLUTIONS  OF  ALCOHOL 
Nximher  of  Colonies  in  One  Loopful  of  Test  Gonococcal  Solution  After: 

SoLOTioN                                                      1  MiN.                10  Mix.               30  Min.  20  Hrs. 

Alcohol,  1  per  cent 300                  300                  300  2000 

5  per  cent SOO                  300                    10  20 

10  per  cent 200                       4                       0  0 

"       20  per  cent 300                       0                       0  0 

30  per  cent 0                      0                      0  0 

50  per  cent 0                      0                      0  0 

"       70  per  cent 0                      0                      0  0 

Alcohol  seemed  to  kill  gonococci  more  readily  than  it  did  the  other 
microorganisms  that  were  tested. 


OTHER  SOLUTIONS 
\umber  of  Colonies  in  Otie  Loopful  of  Test  Gonococcal  Solution  After: 

SOLDTION                                                           1  Min.  10  Mix.  30  Mix.  20  Hrs. 

Tincture  green  soap 0  0  0  0 

Chloroform 0  0  0  0 

Ether 0  0  0  0 

Hydrogen  dicxid 1000  0  0  0 

Thiersch's  solution: 

Salicylic  acid 2  dr.    1 

Boric  acid 12  dr.    [         0  0  0  0 

Water 1  gal.  J 

Potassium  permanganate,  1:  1000 3000  200  0  0 

"            1:4000 3000  20  0  0 

Cupric  sulphate,  1  per  cent 4000  3000  2000  0 

1:100...                              4000  4000  2000  0 

Zinc  sulphate,  1 :  500 500  400  broken  broken 

Boric  acid,  1:  18 3000  2000  2000  0 

(Saturated  solution) 

Potassium  chlorate,  6.6  per  cent .3000  2000  2000  0 

(Saturated  solution) 

Glycerin 6000  6000  4000  1500 

Distilled  water 4000  2000  2000  2000 

(Jlark  and  Wylie^  report  the  following  result:? : 

Method. — Two  cubic  centimeters  of  the  various  dilutions  of  anti- 
septics to  be  tested  were  addd  to  2  c.c.  of  a  salt  emulsion  of  the  gonococ- 
cus.  It  will  immediately  be  seen  that  this  procedure  diluted  one-half 
the  antiseptic  strength  of  the  solution.  To  equahze  this  double  the 
strength  of  the  antiseptic  was  used.  Controls  were  made,  and  the 
average  number  of  colonies  in  a  plate  were  noted.     The  tubes  con- 

'  Clark,  J.  B.,  and  Wylie,  L.  A.:  Jour.  Amer.  Med.  Assoc,  July  29,  1911. 


GONORRHEAL   THERAPY  475 

taining  the  bacteria  were  exposed  to  the  different  germicides  for  a  period 
of  five  minutes,  fifteen  minutes,  and  thirty  minutes,  respectively,  when 
one  loopful  from  each  tube  was  mixed  in  a  tube  of  acetic  agar  and 
poured  into  a  Petri  dish.  These  were  incubated  at  37°  C.  and  ob- 
served at  the  end  of  twenty-four  and  forty-eight  hours. 

A'umber  of  Colonies  in  One  Loopful  of  Test  Solution  After: 

Solution-  Microorganism  5  Mix.  15  Mix.  30  Min. 

Argvrol,  30  per  cent Gonococcus  70  50  10 

10  per  cent ■  90  70  50 

1  per  cent ••  120  50  25 

Protargol,  10  per  cent .  '•  30  15  25 

5  per  cent.  "  90  50  35 

1  per  cent.  "  100  35  25 

Silver  nitrate,  2  per  cent                    -  "  0  0  0 

"           "        1  per  cenl.  "  10  8  0 

"       0.5  per  cent.  "  15  70  6 

1:1000 "  0  0  0 

1:5000 "  0  0  0 

1:10,000 "  525  40  20 

Cresol  comp.,  10  per  cent "  0  0  0 

"           "        5  per  cent.  "  0  0  0 

"        2.5  per  cent.               .  "  0  0  0 

1.2  per  cent.  "  550  300  0 

"          "        0.5  per  cent.              .  "  GOO  500  100 

Collargol,  2.5  per  cent "  SO  100  15 

1.25  per  cent "  120  100  75 

Cargentos,  20  per  cent "  IS  10  0 

"         5  per  cent "  75  0  50 

Derb}''  has  j)()inted  out  that  the  local  action  of  silver  nitrate, 
protargol,  Lugol's  solution,  and  corrosive  sublimate  is  markedly 
retarded  by  the  addition  of  a  serum,  such  as  hydrocele  fluid  or  bovine 
blood,  and  that  it  is  probable  that  the  comparative  efficiency  of  the 
various  antiseptics  depends  largely  upon  this  fact.  Because  of  the 
difficulty  of  cultivating  the  gonococcus  Derby  employed  the  Staphylo- 
coccus aureus  in  his  tests.  He  found  that  silver  nitrate,  when  brought 
in  contact  with  sodium  chlorid,  albumins,  or  urine,  formed  a  dense 
precipitate;  that  it  was  an  effective  germicide — solutions  varying  in 
strength  from  0.5  to  2  per  cent,  killed  the  organism  in  from  two  to  five 
minutes.  An  exposure  of  thirty  seconds  to  a  0.5  per  cent,  solution  was 
generally  sufficient  to  prevent  growth  in  twenty-four  hours,  but  not 
sufficient  to  kill  all  the  cocci.  Protargol  in  1,  2,  4,  10,  and  20  i)er  cent, 
solutions  was  tested,  but  proved  less  efficient  than  the  silver  nitrate. 
Wlien  1  c.c.  of  serum  was  mixed  with  1  c.c.  of  the  silver  preparation 
to  be  tested  a  verj'  marked  dimiruition  of  the  bactericidal  i)ow(>r  of 
all  solution  resulted.  Silver  nitrate,  2  per  cent.,  showed  a  growth  of 
Stai)hyl()coccus  aureus  after  an  exposure  of  from  thirty  to  forty 
miiuitcs;  protargol,  8  percent.,  after  sixty  minutes;    argyrol,  50  per 

'  Derby:   Boston  Med.  and  Surg.  .lour.,  Septemt)or  27,  1906. 


476  GONORRHEA    IN    WOMEN 

cent.,  gave  an  abundant  growth  after  three  and  one-half  hours — the 
longest  interval  allowed  to  elapse.  Other  preparations  showed  similar 
results,  being  affected  in  about  the  same  proportion  as  was  silver  nitrate. 
That  a  similar  effect  was  produced  on  other  germicides  than  the  silver 
preparations  was  shown  by  the  following:  Lugol's  solution,  composed 
of  iodin,  1  part;  potassium  iodid,  2  parts;  and  water,  100  parts, 
killed  the  Staphylococcus  aureus  in  from  thirty  seconds  to  one  minute. 
With  serum  there  was  a  growth  at  the  end  of  five  minutes.  Corrosive 
sublimate  1 :  1000  to  which  serum  was  added  showed  a  growth  after 
thirty  minutes. 

The  reliability  of  the  ordinary  drop  method  has  been  assailed  on  the 
ground  that  no  organic  matter,  such  as  is  present  in  every  case  of 
gonorrhea,  is  employed.  Blyth'  and  Kenwood  and  Hewlett-  have 
described  modifications  in  which  organic  matter  is  included.  Chick 
and  Martin^  have  drawn  attention  to  the  fact  that  the  presence  of  10 
per  cent,  blood-serum  reduces  the  efficiency  of  1  per  cent,  phenol 
about  12  per  cent.  The  effect  upon  emulsified  disinfectants  is  some- 
what greater,  a  0.5  per  cent,  solution  being  reduced  to  from  0.6  to 
0.06  per  cent,  of  its  original  value  as  the  concentration  of  the  serum 
was  increased  from  5  to  30  per  cent. 

Although  laboratory  investigations  such  as  those  just  described 
do  not  reproduce  conditions  similar  to  those  observed  by  the  clinician, 
they  nevertheless  represent  very  nearly  the  relative  bactericidal  proper- 
ties of  the  various  germicides.  Wildbolz,''  of  Bern,  has  performed  a 
series  of  experiments  upon  dogs  with  a  view  to  determining  the  relative 
penetrating  properties  of  protargol  and  silver  nitrate.  Solutions  of 
silver  nitrate  varying  in  strength  from  1:1000  to  1:100,  and  protargol 
in  from  1  to  3  per  cent,  solutions,  were  introduced  into  the  urethra 
and  into  the  eye,  and  the  reduction  of  the  silver  accomplished  by  ex- 
posure to  a  Finsen  light.  So  far  as  penetrating  power  was  concerned 
the  silver  nitrate  easily  took  precedence,  in  some  instances  reaching  the 
subepithelial  tissue.  An  important  series  of  experiments  dealing  with 
osmosis  as  a  factor  in  the  action  of  antiseptics  has  been  carried  out  by 
Seelig  and  Gould."  Although  the  gonococcus  was  not  employed  in 
these  experiments,  they  nevertheless  demonstrate  conclusively  the 
relative  merits  of  certain  germicides.  These  investigators,  realizing 
that  a  point  of  vital  importance  in  dealing  with  the  artificial  destruc- 

'Blyth,  W.:  Analyst,  May,  1905;  Jour.   Soc.  Chem.  Industry,  December,  1006,  vol. 

XXV. 

-  Kenwood  and  Hewlett;  Jotir.  Roy.  San.  Inst.,  1906,  vol.  xxvii,  p.  i. 

^  (^hick,  H.,  and  Martin,  C.  J.:  Jour,  of  Hygiene,  190S,  vol.  viii,  p.  689. 

'  Wildbolz,  H. :  Zeit.  f .  Urol.,  Berlin  and  Leipzig,  1907,  vol.  i,  pp.  185-200. 

<•  Seelig,  M.  G.,  and  Gould,  C.  W.:  Surg.,  Gyn.,  and  Obst.,  March,  1911,  p.  262. 


GONORRHEAL    THERAPY  477 

tion  of  bacteria  is  the  fact  that  these  organisms  are  not  always  free 
on  the  tissue  or  wound  surfaces,  but  occur  in  the  deeper  layers  of  the 
part  afTected,  and  are  often  covered  with  blood  or  exudate;  further- 
more, they  believe  that  the  bacteria  themselves  may  possess  a  more  or 
less  resistant  exterior,  which  serves  as  a  protective  shield  to  their  vital 
protoplasm.  These  investigators  emphasize  the  fact  that,  to  be 
effective,  a  germicide  must  possess  penetrating  powers,  and  their  ex- 
periments are  especially  directed  toward  determining  the  presence  of 
this  property.  With  this  point  in  view,  two  series  of  experiments  were 
performed.  In  the  first,  celloidin  test-tubes,  made  according  to  a 
mcdification  of  the  Harris^  method,  were  employed.  These  capsules 
were  filled  with  broth  cultures  of  different  bacteria  and  immersed  in 
various  watery  solutions  of  antiseptics,  such  as  phenol,  mercury 
bichlorid,  crj'sallic  acid,  and  lysol.  At  intervals  varying  from  ten 
minutes  to  twenty-four  hours  a  loopful  of  the  various  cultures  was  re- 
moved from  the  capsule  and  plated.  With  the  exception  of  one  watery 
antiseptic,  the  organisms  were  unaffected  even  after  so  long  a  period  as 
twenty-four  hours.  This  exception  w-as  iodin.  When  iodin  was 
diluted  to  a  strength  of  12.5  per  cent,  in  water  and  potassium  iodid, 
the  germ-content  of  the  capsule  was  sterilized  in  twenty-five  minutes. 
By  the  starch  reaction  it  was  also  possible  to  demonstrate  that  the  iodin 
had  penetrated  through  the  celloidin  into  the  broth.  After  forty-five 
minutes  enough  had  penetrated  to  color  the  broth  a  walnut  brown. 
Another  series  of  experiments  was  made  with  grain  alcohol  of 
strengths  varying  from  99  to  50  per  cent.  It  was  found  that  the  higlicr 
strength  alcohol  penetrated  the  capsule  very  rapidly;  that  94  percent, 
alcohol  sterilized  the  contents  of  the  c-apsules  in  from  three  to  ten  minutes ; 
that  the  action  of  70  to  SO  jier  cent,  alcohol  was  much  slower,  and  re- 
([uired  seven  and  one-half  hours  to  kill  the  organism,  whereas  50  per 
cent,  alcohol  had  no  apparent  effect  after  a  twenty-four-hour  exposure. 
'J'hese  results  are  in  accord  with  the  recently  published  clinical  reports 
from  tlic  medical  dejjartment  of  the  Prussian  army.'-  Seelig  and  CJould 
found,  therefore,  that  95  per  cent,  alcohol  was  much  more  efficient  than 
80  per  cent.,  but  that  99  per  cent,  was  not  perceptibly  more  effectual 
than  95  per  cent.  I*jX])erimentsw(>re  carried  out  inasimilarmannerwith 
alcohol  in  which  various  g(>rmici(lal  drugs,  such  as  mercury  Ijichlorid, 
plieiioi,  Harrington's  solution,  and  iodin,  had  lieen  dissolved.  They 
found  thai,  with  the  exception  of  iodin,  unadulterated  alcohol  acted  as 
rapi(ll>'  and  {'Ihcieiitly  as  did    the   alcoholic    solutions  of  germicides. 

'  Ilarri.s,  .\.:   .Johns  Hopkins  llospiCil  Hun..  May,  lOOJ,  p.  112. 

'  Kut.schcr,  Otto,  'I'licolc,  and  oliicrs:   V<'r6ITcnt.  a.  d.  (Ichict.  d.  Militiirsanitalswcson, 
lioraasgegcb.  v.  d    incd    Aliih   d    K.  IV-Kricgsniiiiistcriiitn,  11.  41,  1909. 


478  GONORRHEA    IN    WOMEN 

Furthermore,  it  was  discovered  that,  by  the  dilution  of  the  alcohol  or- 
dinarily necessary,  its  action  was  greatly  lessened.  The  iodins,  however, 
apparently  augmented  the  germicidal  properties  of  the  alcohol.  Seelig 
and  Gould  next  employed  an  animal  membrane:  A  small  receptacle  was 
filled  with  the  germicidal  solution  to  be  tested,  and  a  flap  of  skin,  still  alive 
and  attached  to  the  animal,  was  placed  over  the  cup  in  such  a  way  as  to 
make  a  pouch  that  rested  in  the  fluid.  The  same  procedure  was  also 
carried  out  with  living  mesentery  and  omentum.  Into  the  pouch, 
which  was  inunersed  on  one  side  in  the  fluid  to  be  tested,  was  placed 
a  measured  quantity  of  a  broth  culture  of  bacteria.  The  animal 
experiments,  with  but  few  exceptions,  tallied  with  the  results  previ- 
ously secured  with  the  celloidin  capsules.  Alcohol  penetrated  and 
was  effectual  in  direct  proportion  to  its  percentage  strength.  Tincture 
of  iodin  penetrated  and  killed  bacteria  even  more  rapidly  than  did 
strong  alcohol.  Watery  solution  of  bichlorid  1:5000  was  ineffectual 
with  all  membranes,  although  a  1:1000  solution  destroyed  the  germ 
contents  in  forty-five  minutes.  Seelig  and  Gould's'  conclusions  are 
in  direct  opposition  to  those  secured  by  Harrington  and  Walker,- 
who  state  that  although  absolute  alcohol,  or  alcohol  containing  more 
than  70  per  cent,  by  volume,  is  practically  devoid  of  bactericidal 
power,  60  to  70  per  cent,  alcohol  is  a  most  valuable  disinfectant,  killing 
resistant  pathogenic  bacteria  both  in  dry  and  in  moist  conditions  in 
from  three  to  five  minutes. 

Percentage  of 

Agent  Births  Ophthalmia 

Silver  nitrate,  2  per  cent 76,452  0.7030 

Silver  nitrate,  weaker  than  2  per  cent. 36,132  0.4230 

Silver  nitrate  ointment,  2  per  cent 703  '  0.1420 

Silver  acetate,  1  per  cent 6,144  0.1900 

Silver  citrate ..  43  4.6500 

Argentamin,  0.5  per  cent.                                        .  115  2.6000 

Protargol .  .  7,383  0.0270 

ArgjTol .  6,984  0.2500 

Sophol 1,050  0.0950 

Sopholf .  1,595  0.1890 

Corrosive  sublimate                                                    .  1.5,945  0.4069 

Phenol .  2,148  5.4200 

Boric  acid 701  4.5100 

Iodin  trichlorid 761  1.2000 

Salicylic  acid 2,130  1.0300 

Pota.ssium  permanganate,  1:  1000 1,316  0,5300 

Iodoform 1,894  3.1600 

Formalin,  1  per  cent 120  3.3000 

Zinc  sulphocarbonate,  0.5  per  cent 500  0.2000 

Lemon-juice 5,008  1.2700 

Citric  acid 15.000  1.1000 

Aniodol •. i;S44  0.645C 

.\lcohol,  50  and  70  per  cent 720  1.3600 

Hermophenol 250  0.4000 

'  Seelig,  M.  G.,  and  Gould,  C.  W.:  Surg.,  Gyn.,  and  Obst.,  March,  1911,  p.  2.52. 
=  Harrington,  C,  and  Walker,  H.:    Boston   Med.  and  Surg.  Jour.,  1903,  vol.  cxlviii, 
p.  548. 

3  Hannes:  Zent.  f.  Gyn.,  1911,  No.  .50. 


GONORRHEAL    THERAPY  479 

A  further  exposition  of  the  relative  merits  of  some  of  the  gonococ- 
cidal  drugs  is  to  be  found  in  the  preceding  table,  showing  the  number  of 
births  and  the  percentage  of  cases  of  ophthalmia  recorded,  together 
with  the  different  chemical  agents  used  in  the  prophylaxis  of  ophthal- 
mia neonatorum. 1 

Young  and  \Mlliams-  state  that  swabbing  the  uterine  cavity  with 
tincture  of  iodin  has  given  better  results  in  their  hands  than  has  any 
other  form  of  treatment  in  cases  of  miscarriage  and  abortion.  These 
authors  present  the  following  table,  showing  the  results  obtained  with 
iodin  and  with  other  germicides: 

Clean  Cases 

XCXIBER  OF  PeRCENTAQEOF 

Cases  ^Iorbiditt 

Tincture  of  iodin 50  2.0 

Formalin,  0.5  per  cent 7  14.0 

Corrosive  sublimate,  1 :  5000                            305  8.8 

Alcohol,  50  per  cent 239  4.6 

Salt  solution 345  4.3 

Inkected  Cases 

Tincture  of  iodin .25  4.0 

Formalin,  0.5  per  cent .10  20.0 

Corrosive  sublimate,  1 :  .5001)  .    143  19.5 

Alcohol,  50  per  cent. .                                          119  18.4 

Salt  solution 138  11.6 

Silver  Nitrate. — This  is  probably  the  most  efficient  and  widely 
known  gonococcid  that  we  have.  According  to  Marshall  and  Neave,^ 
silver  nitrate  contains  63.6  per  cent,  silver.  Numerous  attempts  have 
been  made  to  substitute  other  less  irritating  preparations  of  silver, 
but  an  extensive  clinical  experience  with  them  has  nearly  always 
shown  silver  nitrate  to  be  the  most  efficient.  In  the  strengths  ordi- 
narily employed,  silver  nitrate  is  a  mild  irritant,  and  this  constitutes, 
perhaps,  its  chief  drawback.  Its  penetrative  and  germicidal  properties 
have  been  fully  demonstrated  by  numerous  clinical  and  experimental 
studies.  In  the  presence  of  urine,  albumin,  or  sodium  chlorid  it  forms 
a  dense  precipitate,  but  it  is,  nevertheless,  an  efficient  germicide.  Gros'' 
has  studied  the  bactericidal  action  of  silver  salts  in  saline  solution. 
Pitzman''  gives  the  following  table,  showing  the  relative  germicidal 
properties  of  silver  nitrate  and  mercurj'  bichloi-jd  with  various  dilutions 
of  serum. 

Diluted  }i         Diluted  H 
Silver  nitrate,  1 :  20,000  =«=.  .  1:S(),()1)()±       1: 60,000  * 

Mercury  bichlorid,   1:10,000  ± 1:40,000*       1: 80,000  ± 

±  indicates  a  turning-point — i.  e.,  slightly  fewer  bacteria  will  grow,  and  slightly  more 
will  be  killed. 

'  Stephcn.son,  .S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  206. 
-  Young,  E.  B.,  and  Williams,  J.  T.;   Boston  Med.  and  Surg.  .lour.,  March  7,  1912,  p. 
364. 

'  Marshall  and  Xeavc:  Brit.  Med.  Jour.,  August  18,  1906,  p.  3.')9. 

*  Gro.s,  O.:  MUnch.  med.  Wochenschr.,  February  20,  1912,  vol.  Ixi,  No.  8. 

'  Pitzinaii,  M.:  .Amor.  Jour.  Ophthal.,  January,  1912,  p.  i. 


480  GONORRHEA    IN   WOMEN 

Silver  Acetate. — Excellent  results  have  been  obtained  with  this 
silver  salt  in  the  treatment  of  ophthalmia  by  Zweifel,'  Leopold, - 
Scipiades,'  and  Dauber.*  Silver  acetate  used  in  a  1  per  cent,  solution 
is  not  only  an  efficient  gonococcid,  but,  according  to  Dauber,''  is 
somewhat  less  irritating  than  is  silver  nitrate.  In  Dauber's  series  the 
salt  was  not  neutralized.  ZweifeP  employed  a  1  per  cent,  solution  in 
the  prophylactic  treatment  of  ophthalmia  in  5222  babies,  of  which 
number  12  developed  ophthalmia.  One  drop  of  a  1.25  per  cent, 
solution  was  put  into  each  eye,  and  any  surplus  was  neutralized  with  a 
weak  salt  solution.  Leopold  did  not  believe  that  neutralization  was 
necessary. 

Argyrol. — Argj'rol,  or  silver  vitellin,  has  been  extensively  employed 
in  the  treatment  of  all  forms  of  gonorrhea.  Stephenson'  asserts  that 
this  preparation  contains  30  per  cent,  of  silver  combined  with  a  protein. 
Marshall  and  Neave^  found  that  argjrrol  contained  20  per  cent,  of  silver. 
These  last-named  authors  state  that  argyrol  is  practically  non-bacterici- 
dal. As  a  projjhylactic  measure  in  preventing  ophthalmia  neonatorum 
excellent  results  may  be  obtained  by  the  use  of  argyrol,  as  has  been 
proved  by  the  fact  that  among  G984  babies  treated  with  this  prepara- 
tion, only  0.25  per  cent,  developed  the  affection.  In  the  Maternity 
Hospital  in  Philadelphia  Dr.  Holloway  and  the  author  have  had  less 
satisfactory  results  with  argyrol  than  were  formerly  obtained  with 
silver  nitrate,  and  hence  have  abandoned  its  use  as  a  prophylactic  agent 
against  ophthalmia  neonatorum.  Derby^  states  that  a  precipitate  is 
obtained  in  the  {Presence  of  albumin  and  of  urine,  though  the  opacity  of 
the  solution  tends  to  disguise  it.  The  germicidal  power  of  argyrol  is 
exceedingly  weak.  In  a  large  series  of  observations  Derby'"  found  that 
a  growth  of  Staphylococcus  aureus  was  obtained  after  exposure  to 
the  10  per  cent.,  25  per  cent.,  and  50  per  cent,  solutions  for  one  hour, 
one  and  one-half  hours,  and  two  hours.  A  diminution  in  the  number 
of  colonies  commonly  appeared  at  the  end  of  twenty  minutes.  Ac- 
cording to  Derby,  the  age  of  the  solution  did  not  seem  to  be  of  impor- 
tance.    Stephenson,"  on  the  other  hand,  emphasizes  the  necessity  of 

'  Zweifel:  Cent.  f.  Gyn.,  December  22,  1900. 

2  Leopold:  Berlin,  kiin.  Woch.,  1903,  No.  33. 

=  Scipiades:  Amer.  Med.,  September  26,  1903;  also  Cent.  f.  Gyn.,  .\pril  11,  1903. 

"  Dauber:  Miinch.  med.  Woch.,  February  16,  190-1. 

•'■  Dauber:  Loc.  cit. 

"  Zweifel:  Cent.  f.  Gyn.,  December  22,  1900. 

'  Stephenson,  S. :  Ophthalmia  Neonatorum,  London,  1907,  p.  194. 

»  Marshall,  C.  R.,  and  Neave,  E.  F.  M.:  Brit.  Med.  Jour.,  .\ugust  IS,  1906,  p.  359. 

»  Derby,  G.  S.:  Trans.  Amer.  Ophthal.  Soc,  1906,  vol.  ii,  p.  2-1. 

'"  Derby,  G.  S. :  Loc.  cit. 

"  Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  1907,  p.  200. 


GONORRHEAL    THERAPY  481 

employing  fre?;h  argyrol.  and  directs  that  it  be  prepared  with  cold 
water  and  kept  away  from  light.  In  the  author's  experience,  argyrol 
is  absolutely  unirritating,  and  seems  to  owe  many  of  its  attributes  to 
the  efficiency  with  which  it  washes  away  discharges.  It  appears  to 
penetrate  deeply  into  the  folds  of  the  inflamed  mucosa,  and  to  disinte- 
grate the  pus,  or  at  all  events  to  cleaiLse  the  tissue.  In  ophthalmia 
it  is  of  especial  value,  owing  to  the  fact  that,  because  of  its  unirritating 
qualities,  it  may  safely  be  employed  even  by  an  unskilled  attendant. 

Protargol. — This  product  is  said  to  contain  8.3  per  cent,  of  silver. 
Derby  found  that  the  Staphylococcus  aureus  was  usually  killed  by  a 
2  or  4  per  cent,  solution  at  the  end  of  from  three  to  five  minutes, 
although  occasionally  a  few  colonies  grew  after  a  ten-minute  exposure. 
Clark  and  Wylie-  showed  that  a  10  per  cent,  solution  failed  to  kill  all 
gonococci  even  after  a  thirty-minute  exposure,  whereas  Post  and  Nicoll- 
state  that  a  10  per  cent,  solution  failed  to  kill  in  one  minute,  but  was 
successful  in  the  ten-  and  thirtj'-minute  exposures.  Protargol  is  less 
irritating  than  silver  nitrate,  although  Esman^  found  20  per  cent,  of 
"silver  catarrh"  among  277  newly  born  infants  treated  prophylactically 
with  a  1  or  2  per  cent,  solution  of  this  preparation,  v.  Herff''  employed 
a  10  per  cent,  solution  as  a  prophylactic  for  ophthalmia  neonatorum 
in  3()()',)  babies,  only  two  infections  resulting,  and  both  of  these  oc- 
curring late.  Naturally,  he  speaks  highly  of  the  preparation,  and  be- 
lieves it  to  be  as  efficient  as,  and  less  irritating  than,  silver  nitrate. 
On  the  other  hand,  Chrobak,'^  after  employing  a  5  per  cent,  solution  in 
the  eyes  of  3000  babies,  has  returned  to  the  use  of  2  per  cent,  silver 
nitrate.     Edgar''  has  had  a  similar  experience. 

Corrosive  Sublimate. — Corrosive  sublimate  is  one  of  the  oldest, 
most  widely  known,  and  most  over-rated  of  all  the  germicides  in  com- 
mon use.  Among  15,945'  infants  treated  with  this  drug  as  a  prophy- 
lactic for  ophthahnia,  0.4069  developed  conjunctivitis.  Post  and 
NicolP  showed  that  the  action  of  the  mercuric  salts  was  slow.  .\ 
mercury  bichlorid  solution  of  1  :.500  failed  to  kill  gonococci  after  a  ten- 
minute  exposure,  and  a  1:1000  solution  after  an  exposiu-c  of  half  an 
hour.     In  Derby's"  experiments  corrosive  sublimate  1 :  1000,  to  which 

'  Clark,  J.  B.,  and  Wylic,  L.  A.:  Jour.  Amor.  Med.  Aasor..  .Fuly  251.  litll. 

-  Post  and  Nicoll:  Jour.  .Vmcr.  Med.  .\.ssoc.,  Xovcml)or  .J,  1!)1(),  |>.  KiiJ.i. 

"  V.  Esman,:   .\rch.  f.  ,\uKcnlicilkunde,  vol.  .xxxviii,  No.  4. 

'  V.  Herff:  Munch,  ined.  Wocli.,  190tj,  No.  20. 

'Chrobak:  Cent.  f.  Gyn.,  Augu-st  20,  1904,  p.  999. 

•Edgar,  J.  C:   Mod.  New.s,  September  2.3,  190.5. 

'  Stephenson,  S.:  Ophthalmia  Neonatorum,  London,  190",  p.  2l)(i. 

«  Post  and  Nicoll:  Jour.  .\mor.  Med.  A.s.soc.,  November  .'),  1910. 

«  Derby,  (!.  S.:  Tran.x.  Amor.  Ophlhal.  Soc,  19011.  vol.  ii.  p.  ■-'(;. 

:u 


482  GONORRHEA    IN    WOMEN 

serum  was  added,  showed  a  growth  of  Staphylococcus  aureus  after  a 
thirty-minute  exposure.  Kronig  and  Paul'  state  that  mercuric  chlorid 
becomes  much  less  germicidal  in  the  presence  of  the  chlorids,  bromids, 
iodids,  and  hydrochloric  acid,  and  that  the  mercury  bichlorid  tablets, 
as  generally  furnished,  contain  substances  that  diminish  their  anti- 
septic powers.  From  the  foregoing  it  may  be  seen  that  distilled,  or 
at  least  filtered,  water  should  be  employed  in  making  up  the  solution. 
Kelly-  asserts  that  poisonous  symptoms,  may  occur  from  the  use  of 
bichlorid  solutions  in  the  form  of  wet  dressings,  douches,  or  irrigations, 
and  cautions  us  to  bear  in  mind  that  many  individuals  possess  an  idio- 
syncrasy for  mercury.  Baux  and  Roques'  have  recently  reported  a 
fatal  case  of  mercuric  poisoning  caused  by  an  intra-uterine  douche. 
Pitzman*  states  that,  in  the  presence  of  albuminous  fluid,  in  order  to 
show  any  action,  mercury  bichlorid  must  exist  as  a  free  excess.  A 
similar  conclusion  was  reached  by  v.  Behring.^  Menge^  speaks  highly 
of  mercury  oxycyanid,  strength  of  1 :  5000,  as  a  surface  wash  in  adult 
females  during  the  acute  or  chronic  stages  of  genital  gonorrhea. 

lodin. — This  is  best  employed  in  various  dilutions  of  the  tincture, 
lodin  has  been  recently  highly  exploited  for  its  germicidal  properties 
as  a  skin  disinfectant.  In  Post  and  NicoU's  series  of  experiments  iodin 
killed  all  four  varieties  of  organisms  experimented  with  in  these  tests. 
Seelig  and  Gould'  have  conclusively  demonstrated  its  penetrative 
and  germicidal  properties.  It  is  undoubtedly  one  of  the  most  efficient 
germicides  know.n.  Its  chief  disadvantage,  however,  in  the  treatment 
of  gonorrhea,  lies  in  its  irritant  properties.  In  certain  cervical  lesions, 
and  in  others  situated  in  such  localities  where  it  can  be  employed,  it 
has  proved  highly  satisfactory.  It  penetrates  deeply,  and  even  in 
weak  solutions  quickly  kills  gonococci  and  other  microorganisms  likely 
to  be  present  in  gonorrhea.  The  strength  to  be  employed  must 
naturally  vary  according  to  the  stage  of  the  disease  present  and  the 
location  of  the  lesion.  The  official  tincture  contains  7  per  cent,  of 
iodin;  by  diluting  this  with  95  per  cent,  or,  better,  absolute  alcohol, 
a  most  efficient  gonococcid  may  be  obtained.  The  experiments  of 
Seelig  and  Gould*  show  that  95  per  cent,  alcohol  possesses  far  greater 

'  Ivionig  and  Paul:  Die  chemischen  Grundlagen  der  Lehi-e  von  der  Giftwirkung  uiid 
Disinfektion,  Leipsig,  1897. 

=!  Kelly,  H.  A.,  and  Noble,  C.  P.:  Gynecology  and  Abdominal  Surgerj'  Pliiladelphia, 
1907,  vol.  i,  p.  10. 

'  Baux,  G.,  and  Roques,  E.:  Rev.  Mems.  de  Gyn.,  d'Obst.,  et  de  Psed.,  January,  1912. 

*  Pitzman,  M.:  Amer.  Jour.  Ophthal.,  January,  1912,  p.  1. 

'  V.  Behring:  Bekampfung  der  Infektions-Krankheiten,  Leipzig,  1894. 

'  Menge,  K.:  Handb.  d.  GeschJechtskrankheiten,  Vienna,  1910. 

'  Seelig  and  Gould;  Surg.,  Gyn.,  and  Obst.,  March,  1911,  p.  262. 

« Seelig  and  Gould:  Surg.,  Gyn.,  and  Obst.,  March,  1911,  p.  262. 


GONORRHEAL    THERAPY  483 

germicidal  properties  than  do  weaker  solutions;  this  should,  therefore, 
rather  than  alcohol  of  weaker  strength,  be  employed  as  a  diluent  of 
tincture  of  iodin.  The  sterilizing  properties  of  iodin  for  skin  disin- 
fection have  been  thoroughly  tested  by  Bovee,^  who  found  that  hair 
and  skin  that  had  been  subjected  to  a  solution  consisting  of  1  part 
of  the  official  tincture  of  iodin  and  1  part  absolute  alcohol  never  pro- 
duced growths.  This  investigator  applied  the  full-strength  tincture 
of  iodin  to  the  cervix,  vagina,  and  vulva  in  the  treatment  of  acute 
gonococcic  infections  in  both  pregnant  and  non-pregnant  women, 
with  signal  success.  As  a  prophylactic  against  ophthalmia  neonatoi-um 
Bovee  painted  the  cervix,  vagina,  and  external  genitalia  with  iodin  shortly 
before  the  os  dilated  in  labor.  Apphed  to  the  uterine  cavity  after  a 
curetage  for  gonorrheal  endometritis  tincture  of  iodin  is  perhaps  the 
best  preparation,  for  not  only  does  it  destroy  many  gonococci  within 
the  tissue,  but  it  also  practically  prevents,  at  least  temporarily,  the 
infection  from  extending  to  the  tubes,  and  thus  safeguards  the  opera- 
tion. In  the  treatment  of  cervical  gonorrhea  tincture  of  iodin  is  most 
efficient,  as  it  penetrates  deeply  into  the  cervical  glands. 

Alcohol. — In  95  per  cent,  strength  or  greater,  alcohol  has  been 
shown  to  be  an  excellent  germicide.  It  not  only  kills  microorganisms, 
but  also  penetrates  dee])ly  into  the  tissues.  As  it  dries  quicklj-,  it 
is  best  employed  in  the  form  of  a  wet  dressing  frequentlj'  renewed. 
In  the  local  treatment  of  gonorrhea  it  is  best  emi)loyed  in  combination 
with  iodin.  Kronig,-  in  a  series  of  720  cases,  used  alcohol  in  50  and  70 
per  cent,  strengths  as  a  prophylactic  for  ophthalmia  neonatorum, 
with  a  resulting  morbidity  of  1.41  per  cent.  Of  the  entire  number, 
however,  3.7  per  cent,  developed  a  medicamentous  conjunctivitis. 
These  experiments  show  that  better  results  may  be  obtained  in  the 
prophylactic  treatment  of  ophthalmia  neonatorum  by  many  other 
drugs.  It  is  worthy  of  note  that,  according  to  Lhermite''  and  Seelig 
and  Could,''  the  osmotic  action  of  alcohol  on  the  skin  may  be  augmented 
by  a  preliminary  application  of  castor  oil  or  other  fatty  substance  to 
the  parts.  Harrington  and  Walker^  found  that,  in  their  experiments 
alcohols  in  strengths  of  from  (iO  to  70  jier  cent,  were  more  bactericidal 
tlian  were  the  stronger  percentages.  These  authors,  however,  em- 
ployed the  old  thread  method,  and  this  is  i)rol)ably  responsil)le  for  the 

'  Hovce:   Anier.  Joiir.  Obst.,  July,  I'.lll,  j).  <.)1. 

'  Kronig,  A.:  Cent.  f.  Gyn.,  March  2,  1901,  p.  23"). 

»  Lhermite:  Ann.  de  Cliem  et  de  Phy.sique,  18.5.5,  3me  So.  .\liii,  p.  1211. 

*  Seelig  and  Gould:  Surg  ,  Gyn.,  iind  Obst.,  March,  litll,  p.  2(12. 

'  Harrington,  C,  and  Walker,  H.;   Ho.ston  Med.  and  Surg.  .lour.,  May  21,  1!M)3,  p.  .MS. 


484  GONORRHEA    IN    WOMEN 

results  obtained.  Kronig^  has  demonstrated  experimentally  that 
after  several  applications  solutions  of  thymol  in  60  per  cent,  alcohol  in 
the  strength  of  1  per  cent,  or  over  were  efficient  in  disinfecting  the  skin. 
Bits  of  skin  treated  with  this  solution  showed  no  bacteriologic  growth. 

Shumburg-  and  Marquis'  have  recently  called  attention  to  the 
value  of  alcohol  as  a  disinfectant  and  germicide. 

Formalin. — Menge,  in  his  recent  monograph  on  Gonorrhea,  states 
that  formalin  is  one  of  the  best  gonococcids  known,  and  is  especially 
useful  in  chronic  gonorrhea  of  the  endometrium  on  account  of  its 
non-caustic  properties,  v.  Franque^  and  Gerstenberg^  also  recommend 
formalin  for  the  treatment  of  endometritis. 

ZweifeP  employed  a  1  per  cent,  solution  as  a  prophylactic  measure 
against  ophthalmia  neonatorum  in  a  series  of  120  cases,  of  which 
number  3.3  per  cent,  developed  ophthalmia.  As  a  cervical  application 
in  gonorrhea  formalin  gives  excellent  results. 

Picric  Acid. — This  is  an  excellent  gonococcid,  the  merits  of  which 
have  not  been  sufficiently  recognized.  Ehi-enfield^  has  shown  that  a 
12  per  cent,  (saturated)  aqueous  picric  acid  solution  was  50  times  more 
germicidal  than  a  1  per  cent,  phenol  solution.  MitchelP  states  that 
picric  acid  is  a  strong  germicide,  and  that  no  untoward  results  follow 
applications  of  a  1  per  cent,  aqueous  or  alcoholic  solution  to  large  areas 
of  skin.  This  author  bases  his  opinion  upon  clinical  experience  and 
upon  a  series  of  experiments  in  which  the  glass-rod  method  was  em- 
ployed. He  recommends  picric  acid  as  a  skin  disinfectant.  Polak" 
employs  this  drug  in  the  treatment  of  cervical  gonorrhea.  Pyri'"  and 
Porosz"  also  recommend  this  drug  in  the  treatment  of  gonorrhea. 

CoUargol.^ — Marshall  and  Neave'-  report  that  this  preparation  con- 
tains 86.6  per  cent,  of  silver,  and  that  it  is  not  bactericidal.  It  is 
said  to  be  a  colloidal  solution  of  metallic  silver.  Derby''  states  that 
it  forms  a  somewhat  opaque  solution,  and  that  no  precipitate  with 

'  Kronig:  Experimentellcs  und  Klinisches  zur  Disinfektion  des  Operationsfeldes  mit 
Thymol-Spiritus;  A.  Hoffmann,  from  the  Greifswald  Surgical  Clinic  of  Professor  Fr. 
Kronig,  Beitrage  zurklin.  Chir.,  vol.  Ixxvi,  H.  2;  also  Zentralbl.  f.  Cliir.,  1911,  vol.  xxxviii, 
p.  827. 

2  Shumburg:  Deut.  med.  Woeh.,  February  29,  1912. 

'Marquis,  E.:  Soc.  de  Chir.  de  Paris,  November  22,  1911:  Bull,  et  Memoires,  1911, 
No.  35,  p.  1265. 

■•  V.  Franque:  Munch,  med.  Woch.,  1903.  '  Gerstenberg:  Centralbl.  f.  Gyn.,  1900. 

«  Zweifel:  Cent.  f.  Gyn.,  December  22,  1900. 

'  Ehrcnfield:  Jour.  Amer.  Med.  Assoc,  February,  1911,  vol.  Ivi. 

s  Mitchell,  O.  W.  H.:  Ann.  Surg.,  Philadelphia,  1911,  vol.  liv,  p.  230. 

"  Polak:  Personal  communication. 

'»  Pyri:  Gacela  Med.  Catal.  Rev.  Espan.  d.  Sifi.  y  Dermat.,  190-1,  No.  61. 

1'  Porosz:  Wien.  med.  Pre.sse,  1902,  Nos.  10  and  11. 

>-  Marshall  and  Neave:  Brit.  Med.  Jour.,  August  18,  1906,  p.  359. 

'1  Derby,  G.  S.:  Trans.  Amer.  Ophthal.  Soc,  1908,  vol.  xi,  p.  23. 


GONORRHEAL    THERAPY  4S5 

albumin  or  urine  could  be  detected.  This  observer  found  its  bacteri- 
cidal powers  to  be  comparatively  weak,  as  a  growth  of  Staphylococcus 
aureus  could  be  obtained  at  the  end  of  twenty  minutes  after  using  the 
4  per  cent,  solution.  With  a  1  per  cent,  solution  a  growth  was  obtained 
at  the  end  of  one  hour  (drop  method). 

Gennerich^  reports  the  results  obtained  with  this  preparation  in 
the  treatment  of  arthritis  and  other  acute  sequel*  of  gonorrhea. 

Phenol. — Since  the  days  of  Lister  phenol  has  been  extensively 
employed  as  a  germicide.  In  1876  Schiess,-  and  five  years  later  jNIac- 
donald.'  employed  phenol  as  a  prophylactic  against  ophthalmia  neona- 
torum. Of  2148  infants  treated  with  phenol,  5.42  per  cent,  devel- 
oped ophthalmia  neonatorum  f Stephenson^).  Slack  and  Wade*  speak 
highly  of  phenol  as  a  germicide.  Owing  to  its  destructive  and  irritant 
properties  in  strong  solutions  and  its  non-penetrating  action  in  weak 
solutions,  as  a  gonococcid  phenol  is  inferior  to  many  other  drugs. 

Ichthyol. — This  preparation  has  been  highly  recommended  as  an 
antisej)tic  and  alterative  in  the  treatment  of  gonorrhea.  It  is  ob- 
tained from  the  distillation  of  bituminous  mineral  rich  in  fossil  fish. 
The  connnercial  product  represents  various  salts  of  sulphichthyolic 
acid,  the  latter  being  obtained  by  treating  the  oil}'  distillate  with 
concentratetl  sulphuric  acid  (Stevens'').  Ichthyol  is,  as  a  rule, 
unirritating,  l)ut  occasionally,  either  as  the  result  of  impurities  or 
peculiar  sensibility  of  the  patient,  the  preparation  maj'  produce  marked 
inflammation.  Dawbarn"  suggests  that  this  may  be  caused  by  ich- 
thyol manufactured  from  originallj'  poisonous  fish. 

Lysol  is  said  to  contain  about  50  per  cent,  of  cresol,  and  mixes 
with  water  to  form  a  clear  or  opaque,  saponaceous,  frothy  fluid.  It  is 
a  moderately  powerful  germicide,  and  has  been  extensively  employed 
in  various  strengths  for  vaginal  irrigations.  Post  and  NicolP  found 
that  1.5  percent,  solution  killed  all  microorganisms,  but  that  a  1:10()() 
solution  was  ineffective. 

Boric  Acid. — In  701  cases  in  wliicli  boric  acid  was  employed  as  a 
prophylactic  against  ()i)htlialmia  neonatorum,  4.51  per  cent,  developed 
ophthalmia  neonatorum  (Stephenson").  In  solutions  of  2  to  6  per 
cent,   its  germicidal  powers  are  comparatively  weak.     In  Post   and 

'  Gennericli:   Munch,  med.  Woch.,  April  9,  1912. 

'Schies.s:  Corr.-Blatt  f.  Sohweiz.  .\crzte,  1876,  p.  074. 

'  Mftcdoiiiil.J,  A.:   Ivliuhiirgh  Mod.  Jour.,  ISSl,  p.  114. 

*  Steplien.son,  .S.:  Oplithiil.  Noonat.,  LorKlori,  1907,  p.  20G. 

'  Slack,  F.  H.,  and  Wiuiv,  K.  M.:  Amor.  .Jour.  Pul).  Hyg..  1910,  vol.  xx,  No.  (i,  p.  S3S. 

"  Slevcn.s,  A.  A.:  A  Maruial  of  Thorapoutics,  1890,  p.  171. 

'  Dawbarn,  1{.  II.  M.:  .New  York  Med.  Jour.,  Scptembor  .3,  1910,  p.  400. 

'  Post  and  Xicoll:  Jour.  Arner.  Med.  .-V.ssoc,  November  .5,  1910,  p.  10:i."). 

•Steplien.son,  S.:  Oplithal.  Nconat.,  London,  1907,  p.  200. 


48G  GONORRHEA    IN    WOMEN 

Nicoll's^  experiments  a  saturated  solution  failed  to  kill  bacteria  in 
thirty  minutes.  Owing  to  its  unii-ritating  properties,  boric  acid  has 
been  employed  extensively  for  vaginal  irrigations,  either  alone  or  in 
combination  with  alum,  phenol,  or  common  salt. 

Further  references  to  this  subject  may  be  found  in  the  works  of 
INIuUer,-  Puckner,^  Cragin,^  Cooper,''  Lohnstein,^  Anderson  and  Mc- 
Clintic,"  Kendal  and  Martin,^  and  Phelps.' 

SERUM  AND  VACCINE  THERAPY  FOR  GONORRHEA 
Many  divergent  views  are  held  as  to  the  benefits  to  be  derived  from 
the  treatment  of  gonorrhea  by  either  sera  or  vaccines.  Undoubtedly, 
many  factors  contribute  to  the  difference  of  opinion  upon  this  subject. 
The  advantages  to  be  derived  from  the  employment  of  either  the 
serum  or  the  vaccine  treatment  vary  largely  with  the  lesion,  the  stage 
of  the  disease,  the  type  of  infection  present  (pure  gonococcal  or  mixed 
infection),  its  severity,  and  the  quality  and  quantity  of  the  serum  or 
vaccine  employed.  As  a  general  rule,  to  which  certain  exceptions 
exist,  it  may  be  stated  that  systemic  infections  or  local  manifestations 
of  systemic  infections  are  more  amenable  to  this  form  of  treatment  than 
is  simple  uncomplicated  gonorrhea  of  the  genital  tract.  An  exception 
to  this,  however,  is  gonorrheal  vulvovaginitis  in  children,  this  form 
of  treatment  having  been,  usually,  highly  successful  in  these  cases. 
Chronic  gonorrheal  conditions  are  generally  more  markedly  benefited 
by  the  administration  of  serum  or  vaccine  than  are  acute  lesions. 
In  gonorrheal  arthritis  the  results  obtained  from  this  form  of  treatment 
have  been  most  excellent.  On  the  other  hand,  little  can  be  hoped  for 
in  the  treatment  of  pelvic  inflammatory  disease.  The  warning  of 
Wright^"  has  been  amply  justified.  This  writer  draws  especial  atten- 
tion to  the  paralytic  action  brought  to  bear  on  the  leukocytes  by  the 
tryptic  ferments  liberated  from  disintegrating  pus-cells  in  abscess- 
cavities,  and  to  the  futility  of  attempting  to  cure  them  by  vaccine 
therapy  unless  they  are  emptied  frequent!}^  and  flooded  with  opsonic 
fluid  fresh  from  the  circulatory  blood. 

Indication  for  the  Use  of  Antigonococcic  Serum  and  for  Vaccines. 
— When    the    condition  of    the    patient    is   such    that    she    cannot 

'  Post  and  NicoU:  Jour.  Amer.  Med.  Assoc,  November  5,  1910,  p   1035. 

2  MuUer:  Berlin,  thierarztl.  Woch.,  1902,  p.  267. 

'  Puckner,  W.  A.:  Jour.  Amer.  Med.  Assoc,  1906,  p.  1256. 

■*  Cragin,  E.  B.:  Jour.  Surg.,  Gyn.,  and  Obst.,  1907. 

'  Cooper,  J.  B. :  The  Ophthalmoscope,  1907,  p.  16. 

«  Lohnstein:  Monatsb.  {.  Urologie,  1904. 

'  Anderson,  J.  F.,  and  McClintic,  T.  B.:  Jour.  Infec  Dis.,  January  3,  1911. 

«  Kendal,  A.  I.,  and  Martin,  E.:  Jour.  Infec.  Dis.,  March  6,  1911. 

'  Phelps,  E.  B.:  Jour.  Infec  Dis.,  Januarys,  1911. 

'"  Wright:  Quoted  by  Ballenger:  Trans.  Amer.  Med.  Assoc,  May  30,  190S,  p.  17S4. 


GONORRHEAL    THERAPY  487 

produce  her  own  antibodies,  these  may  be  partially  supplied  by 
the  injection  of  serum.  Serum  is  perhaps  more  dangerous  than 
vaccine.  Williams,  Cragin,  and  NewelP  state  that  in  gonorrheal 
arthritis  and  ureteritis  vaccine  therapy  is  a  valuable  adjunct  to  other 
forms  of  treatment,  and  may  occasionally  alone  lead  to  a  cure. 
It  appears  to  be  useless  in  acute  infections,  whereas  in  the  treatment  of 
vulvovaginitis  of  cliildren  it  is  perhaps  more  efficient  than  any  other 
form,  but  even  in  these  cases  a  cure  does  not  alwaj^s  result.  In  certain 
cases  of  endometritis  and  as  a  postoperative  remedy  for  pelvic  inflam- 
mation it  may  be  of  value.  Stellwagen-  believes  that  antigonococcic 
serum  is  indicated  in  all  complicated  cases  of  gonorrhea,  and  he  has 
ne\Tr  seen  any  ill  effects  follow  the  treatment  except  a  slight  eruption 
that  soon  disappeared.  Butler  and  Long^  report  the  results  obtained 
in  a  series  of  girls  suffering  from  vulvovaginitis  treated  with  vaccine. 
The  patients  varied  in  age  from  one  and  one-half  to  two  years.  A 
control  series  of  cases  was  treated  locally  without  the  use  of  vaccines. 
In  the  series  treated  with  vaccines  the  discharge  diminished  and  the 
gonococcus  disappeared  more  quickly  than  in  the  series  treated  bj' 
local  measures  alone.  Butler  and  Long  employed  the  Wright  technic, 
and  were  guided  in  then-  treatment  by  the  opsonic  index.  In  certain 
eye  lesions  vaccines  and  sera  have  given  excellent  results.  Stoner^ 
has  collected  the  following  statistics  relative  to  the  benefits  to  be  de- 
rived from  vaccine  therapy  in  various  conditions: 

GO.\OCX)CCIC  SIOVTK'EMIA 
Authors  Cases         Cored       Improvkd  Rkmakks 

Eyre  (Lancet,  1909,  vol.  ii,  p.  70) 1  0  1 

Dieulafoy  ( Prcssc  Mwlieale,  1909.  p.  353) i  2  0 

Irons  (Arch.  Intcrnat.  Mod.,  1908,  vol.  v,  p. 

276) 3  0  0       3notl)ciiclili'.l. 

Miller  (Ghi-sgow  Med.  .Jour.,  1908,  p.  3.56)  .1  1  0 

7,31 


Treatment  was  not  restricted  to  vaccines. 

Illman  and  Duncan''  report  the  history  of  a  ca.se  of  goiiorrlu^al 
proctitis  successfully  treated  with  gonococcic  vaccine.  Ballenger'' 
publishes  the  histories  of  three  cases  of  gonorrheal   urethrocystitis 

'  Williams,  .1.  \V.,  Cragin,  E.  H.,  and  Xewell,  F.  .'<.:  Surg.,  Cvn.,  and  Oli.sl.,  1910,  v(.l. 
xi,  2,  p.  12. 

'  SlolhvaKen,  T.  C:  Tlicrnp.  Gaz.,  1910,  vol.  iii,  Scr.  26,  No.  34,  p.  249. 

'  Huller,  W.  ,1.,  an<l  Long,  ,J.  P.:  III.  Med.  .Jour.,  1908,  vol.  xiii,  p.  .538. 

*  Sinner,  H.  \\'.:  .\nier.  .lour.  Mc-<1.  .Sri.,  1911,  new  scries,  vol.  cxii,  pp.  1,SG-213. 

'  Illman  and  Duncan:    X(;w  York  Med.  .lour.,  1908,  p.  1228. 

"  Halleniter:  .I.,ur.  Anicr.  Mc.l.  .\saoc.,  1908,  vol.  i,  p.  1784. 


488 


GONORRHEA    IN    WOMEN 


treated  with  vaccine  with  much  benefit.  Tuttle^  describes  a  case  of 
gonorrheal  salpingitis  cured  by  vaccines.  Roark-  records  the  history 
of  a  case  of  gonorrheal  keratosis  that  was  apparently  greatly  benefited 
by  the  use  of  this  form  of  treatment. 

VAGINITIS  IN  CHILDREN 


Ohlmacher  (Jour.  Amer.  Med.  Assoc, 
190S,  vol.  xlwii,  p.  571) 

Butler  (The  Practitioner,  1905,  vol. 
Ixxvii,  p.  589) 

Hamilton  (Jour.  Infec.  Dis.,  1908,  vol. 
V,  158) 

Churchill    (Jour.   Amer.    Med.    Assoc, 

1908,  vol.  h,  p.  1298) 

Butler  (Jour.  Amer.  Med.  Assoc,  1908, 

vol.  li,  p.  1301) 

Ladd  and  Russ  (Cleveland  Med.  Jour., 

1909,  p.  135) 

Thomas  (Jour.  Amer.  Med.  Assoc,  1910, 

vol.  liv,  p.  362) 

H.araiUon    (Jour.   Amer.    Med.    Assoc, 

1910,  vol.  liv,  p.  1196) 


Casls 

Cured 

2 

2 

12 

10 

67 

0 

17 

10 

25 

0 

1 

0 

S4 

76 

211 

100 

0         I  5    not    cured,    3 
lost. 


100 


6  not  benefited. 


Hamilton'*  gives  the  following  table,  showing  the  results  obtained 
by  vaccine  treatment  of  gonorrheal  vaginitis  compared  with  irrigation 
methods. 


Tbeat.mext  Cases  Cured         Not  Cured  Lost      Per  Cent  Cored 

Irrigation 260  1 5S  53  49  60 

Vaccine 84  76  5  3  90 

.\veragc  length  of  time  under  active  treatment  by  the  irrigation  method,  10.1  months. 

.A.vei-age  length  of  time  under  active  treatment  by  the  vaccine  method,  1.7  months. 

Morrow  and  Bridgman*  present  the  following  table,  showing  the 
results  obtained  in  the  treatment  of  300  cases  of  gonorrhea  in  girls: 


Number  of 

Cases 

Treated 

17 
101 

30 
32 

Time  Requ 

RED  FOR  Germs  t 

o  Disappear 

TREAT.MENT  L'SED 

Least 
fmontl«) 

1 

1 

17-30 
10-30 

Greatest 
(months) 

24 
5 

s 

4 

4 

.\verage 
(months) 

Four  per  cent,  silver  nitrate 

\':iccine  alone 

\';ci-i-iru>  and  ichthyol 

11 

4 
4 

VaciiiK!  and  25  per  cent,  .silver 
nitrate 

25  per  cent,  silver  nitrate. 

2 

'  Tuttle:   Med.  Rec,  1910,  p.  2052. 

2  Roark,  B.  H.:  Jour.  Amer.  Med.  Assoc,  November  23,  1912,  p.  2030. 

=  Hamilton,  B.  W.:  Jour.  Amer.  Med.  A.ssoc.,  April  9,  1910,  p.  1196. 

■■  Morrow,  L.,  and  Bridgman,  O.:  Jour.  Amer.  Med.  Assoc,  May  25,  1912,  p.  1.564. 


GONORRHEAL    THERAPY 


489 


These  authors  state  that  in  those  cases  in  which  vigorous  local 
treatment  alone  was  employed  the  results  have  been  quite  as  satis- 
factory as  when  the  treatment  has  been  combined  with  vaccine,  and 
that  in  the  case  of  little  girls,  apart  from  the  question  of  expense,  the 
vaccine  treatment  alone  is  not  entirely  satisfactory^  because  of  the 
tendency  of  the  disease  to  recur.     Weinstein'  reports  the  result  ob- 

GONORRHEAL  ARTHRITIS 


Cases         Ccred         Improved 


Ohimacher  (Jour.  Amer.  Med.  Assoc, 
1907,  vol.  xhdii,  571) 

Cole  and  Meakins  (Johns  Hopkins  Hos- 
pital Bull.,  1907,  vol.  x\-iii,  p.  223) .  .  . 

Mc.\rthurs    (Surg.,    Gvn.,    and    Obst., 

1907,  vol.  V,  p.  373) 

Bristow  (Xew  York  State  Jour.  Med., 

1908,  vol.  Wn,  p.  121) 

Irons  iJour.  Infec.  Dis.,  1908,  vol.  v,  p. 

279 1 

Illinaii   'New   York  Med.  Jour.,   1908, 

p.  1228) 

\Ahilcmore    fPhilippine    Jour.    Science, 

1908,  p.  421) 

Mainiiii  1 1'nssc  Mddirale.  1909,  p.  40)  .  . 
I.add  ami  Kiiss  (Cleveland  Med.  Jour., 

1909,  p.  135) 

Maute  (Coinp.  Soc.  dp  Biol.,   1909,  p. 

517) 

Oa.stler    (Amer.    Jour.    Obst.,    1909,    p. 

594 1 

Dieulafoy    (Presse    Medicale,    1909,    p. 

353) 

Wliite  and  Evre  (Lancet,  London,  1909, 

vol.  i,  p.  1586) 

Evre    and    Stewart    (Lancet,    London, 

"1909,  vol.  ii,  p.  7(i) 

Thoina.s  (Jour.  Amer.  Med.  .As.soc.,  1910, 

vol.  liv,  p.  302) 

Hartwell  (Ann.  Surg.,  1900,  vol.  ii,  p. 

939) 

Macdonald   (Jour,  .\inpr.  Med.  Assoc, 

1910,  vol.  liv.  p.  9(it)) 

Jack  (CilaxRow  Med.  Jour..  1910,  p.  255) . 
Miller  (Ola,sgow  Med.  Jour.,   1910,   p. 

262) 

Schultz  (J.  H.  Schultz,  neulscli.  nicd. 
Woch..  December  II.  I'll! 


11 
102 


4  not  benefited. 


3  not  benefited. 


9  not  benefited. 
4  not  bciiefiled. 


5  not  benefited. 
25  not  benefited. 


taiued  in  tlie  treatment  of  15  little  girls  treated  with  vaccines.  A  cure 
was  effected  in  every  case  in  which  gonococci  were  demonstiable  in 
tlie  vaginal  discharge.  The  author  concludes  that  the  treatment  was 
entirely  satisfactory. 

Srliiiidler-  recommends  vaccines  for  the  treatment  of  arthritis,  but 

'  Weinsleiti:   Miindi.  med.  Woch.,  1910,  No.  14,  p.  762. 
=  Scliindler:   Berlin,  klin.  Woch.,  vol.  xlvii.  No.  31. 


490 


GONORRHEA    IN   WOMEN 


declares  that  caution  is  necessary,  as  the  infection  may  be  mixed  with 
bacteria  over  wliich  gonococcal  vaccines  will  exert  no  influence,  or  that 
the  tissues  may  already  be  so  seriously  destroyed  by  the  disease  as  to 
secure  but  httle  benefit  to  the  patient. 

GONORRHEAL  CONJUNCTIVITIS 


Authors 

Cases 

GnBED 

Improved 

Remarks 

Ohlmacher    (Jour.    Amer.    Med.    Assoc, 
1907  vol  xl\aii  p.  571) 

3 

1 

2 

0 
2 

1 

0 
0 

Eyre  and  Stewart  (Lancet,  London,  1909, 

1  not  benefited. 

Miller    (Glasgow    Med.    Jour.,    1910,    p. 
262) 

Total.. 

(i               4 

1 

1  not  benefited. 

GONORRHEAL  IRITIS 

Authors 

Cases 

Cored 

Improved 

Remarks 

Eyre  and  Stewart  (Lancet,  London,  1909, 
vol.  ii,  p.  76) 

Miller  (Glasgow  Med.  Jour.,  1910,  p. 
262) 

Shumway  (Ann.  Ophthalmologv,  1910, 
vol.  xix,  p.  233) 

.       4 
1 
1 

3 
1 
1 
■5 

1 
0 
0 

Total 

1) 

1 

Bryan^  states  that  serum  has  proved  of  value  in  cases  of  gonorrheal 
iritis,  but  that  it  is  useless  in  conjunctivitis.  Schmidt-  believes  that 
the  cure  of  cervical  gonorrhea  is  in  many  cases  doubtful.  This  author 
treated  24  cases  of  gonorrheal  cervicitis,  employing  two  kinds  of  vac- 
cine— that  of  Bruck  and  that  of  Reiter.  Twelve  of  the  cases  were 
entirely  cured.  Microscopic  examination  of  the  discharge  from  these 
cases  was  made  four  to  ten  weeks  after  treatment.  The  discharge 
examined  was  secured  in  each  case  shortly  after  the  menstrual  period. 
Eight  of  the  cases  were  treated  with  arthigon  of  Bruck,  and  16  with 
Reiter's  vaccine.  Schmidt's  conclusions  are  that  in  cervicitis  vaccines 
sometimes  effect  a  cure;  that  the  best  results  are  obtained  in  vulvo- 
vaginitis; in  arthritis  only  relief  of  pain  is  secured.  No  good  results 
follow  the  use  of  vaccines  in  cases  of  urethritis.  No  local  or  general 
ill  effects  were  observed  from  the  use  of  the  vaccines.  Heinsius' 
reports  treating  10  cases  of  gonorrhea  in  women  with  autogenous 

'  Bryan,  C.  W.  G.:  Brit.  Med.  Jour.,  March  30,  1912. 
2  Schniidt,  A.:  Munch,  mod.  Woch.,  October  10,  1911. 
=  Heinsius,  F.:   Monats.  f.  Gcb.  u.  Gyn.,  April,  1911,  p.  426. 


GOXOKKHEAL    THERAPY  491 

vaccine.  All  were  improved.  Friedlander^  and  Farbach-  report 
similar  results.  Slingenberg^  reports  the  results  obtained  in  a  series  of 
girls  and  women  treated  with  polyvalent  vaccine  in  Treub's  clinic. 
The  children  suffered  from  vulvovaginitis,  and  the  women  from  various 
adnexal  lesions.  All  were  out-patients,  so  that  temperature  control 
w'as  not  always  possible.  In  some  of  the  patients  the  treatment  was 
very  successful.  In  some  reaction  was  intense  even  when  minute 
doses  were  employed,  so  that  Slingenberg  urges  caution  in  its  use. 
In  others  the  reaction  was  mild.  This  author  asserts  that  a  diag- 
nostic course  of  inoculations  with  progressive  dosage  which  fail  to 
induce  any  reaction  can  be  accepted  as  excluding  gonorrhea.  Van  de 
^'elde'  declares  that  an  unusually  low  opsonic  index  generally  indi- 
cates gonorrhea,  and  a  diagnostic  vaccination  will  decide  the  matter 
in  doubtful  cases,  although  caution  should  be  observed.  Adnexal 
lesions  swell  and  grow  tender  during  the  negative  phase  after  the 
inoculation.  Recent  or  active  inflammation  of  the  tubes  or  ovaries 
contraindieates  the  diagnostic  use  of  vaccines,  as  exacerbations  may 
result  under  these  conditions.  Van  de  Velde  suggests  beginning  all 
cases  with  a  small  test  vaccination,  and  controlling  the  findings  with 
the  opsonic  index^  By  this  .means  valuable  information  may  be 
derived  without  danger  to  the  patient.  Recio^  reports  favorably  on 
the  diagnostic  A'alue  of  vaccines  in  cases  of  gonorrhea. 

Antigonococcic  Serum. — In  1906  Torrej'"  briefly  described  an  anti- 
gonococcic  serum  that  had  been  found  efficacious  in  the  treatment  of 
gonorrheal  arthritis,  and  in  a  later  communication  Rob(>rts  and  Torroy" 
confirmed  the  previous  work  of  the  latter  author. 

Preparation  of  Antigonococcic  Serum. — The  onl.\'  sciuin  with  which 
the  author  has  had  any  experience  is  that  manufactured  bj'  Parke, 
Davis  and  Co.  This  is  prepared  from  the  blood  of  healthy  rams  that 
have  been  treated  w'ith  gradually  increasing  doses  of  dead  and  live 
cultures  of  virulent  .strains  of  gonococci.  Careful  attention  is  given 
to  the  treatment  of  the.se  animals,  and  great  care  exercised  in  the  col- 
lection of  the  l)lood  and  in  the  separation  of  the  serum.  The  process 
of  obtaining  the  serum  from  the  blood  is  essentially  the  same  as  that 
emi)li»>i'ii  in  the  pruductinn  (if  antidii)litlii'ri('  ami  other  sera.     Four- 

'  FriudliiiKlcr:   IkTlin.  kliii.  Woch.,  1910,  No.  30. 
'Farbach:    Kentucky  Med.  .Jour.,  September  15,  1912. 
'  Slingenberg,  B.:  Arch.  f.  Gyn.,  Berlin,  1912,  vol.  xcvi.  No.  2. 

'Van  de  Vcldc,  T.  H.:  Monats.  f.  Geb.  u.  Gyn.,  Berlin,  April,  1912,  vol.  xxxv, 
.\o.  4. 

'  Recio,  A.:  Hevista  de  Medicina  y  Cirugia,  Ilav.ana,  April  2."),  1912. 
•Torrey,  J.  C:  Jour.  Amor.  Med.  Assoc,  .January  27,  190l>,  p.  2lU. 
'  Roberts,  J.,  and  Torrey,  J.  C:  Jour.  .Vnier.  Med.  A.ssoc.,  Si'ptpnibcr  14,  1907. 


492  GONORRHEA    IN    WOMEN 

tenths  of  1  per  cent,  of  trikresol  is  added  as  a  preservative.  Tlie  sei-um 
is  stored  in  hermetically  sealed  glass  bulbs  or  syringe  containers. 
These  hold  2  c.c.  each. 

Dosage. — This  is  usually  2  c.c.  of  serum  given  as  a  single  dose,  and 
it  may  be  repeated  in  one,  two,  three,  or  four  days.  Roberts  and 
Torrey^  recommend  that,  as  a  rule,  the  injection  be  administered  every 
other  day.  In  this  regard,  however,  they  state  that  the  physician 
must  be  guided  by  the  general  condition  of  the  patient,  the  degree  of 
reaction  to  the  serum,  and  the  variety  of  serum  employed.  In  some 
instances  it  is  necessary  to  allow  an  interval  of  from  four  to  six  days 
to  elapse  between  the  injections.  Schmidt^  recommends  that  2  c.c.  be 
given  for  two,  four,  or  five  successive  days,  and  he  has  at  times  in- 
creased the  dose  to  4  c.c,  with  intervals  of  one  to  five  days,  giving  as 
much  as  6  or  8  c.c.  at  intervals  of  five  days.  He  has  never  seen  serious 
results  follow.  The  frequency  of  the  dose  must  be  partially  governed 
by  the  individual  case. 

Technic  of  Administration. — The  best  site  for  making  the  injection 
is  at  a  point  where  there  is  considerable  subcutaneous  tissue,  such  as  the 
buttock  or  thigh.  Strict  asepsis  must  be  maintained  throughout  the 
entire  operation.  The  skin  should  be  sterilized  by  means  of  soap 
and  water,  alcohol,  and  a  5  per  cent,  solution  of  phenol.  This  dis- 
infectant is  recommended,  as  it  is  claimed  that  the  anesthetic  proper- 
ties of  the  phenol  diminish  the  pain  of  the  injection.  The  serum 
should  be  injected  quite  slowly.  In  order  to  make  certain  that  the 
needle  has  not  punctured  a  blood-vessel  Schmidt^  recommends  that 
the  syringe  be  detached  from  the  needle  after  its  insertion  in  order  to 
see  that  no  blood  follows.  The  same  author  suggests  that  a  small 
quantity  of  sterile  normal  salt  solution  be  injected  after  the  serum, 
so  as  to  prevent  any  of  the  latter  from  escaping  when  the  needle  is 
withdrawn.  The  wound  should  be  sealed  with  collodion.  At  the 
completion  of  the  operation  the  site  of  the  injection  should  be  lightly 
massaged. 

Reaction. — This  varies  considerably  in  different  individuals.  Local 
swelling,  redness,  heat,  itching,  burning  sensations,  and  soreness  about 
the  point  of  injection  may  be  present  in  varying  degrees  in  some 
patients.  In  others,  Uttle  or  no  reaction  is  observed.  This  reaction 
is  not  caused  by  the  presence  of  an  antibody  on  the  serum,  but  is  due 
to  the  local  toxic  action  of  the  serum  itself,  and  is  partly  referable  to 
the  idiosyncrasy  of  the  individual  patient.     Malaise,  slight  eleva- 

'  Roberts,  J.,  and  Torrey,  J.  C. :  Ibid. 

2  Schmidt,  L.  E.:  Therap.  Gaz.,  September  15,  1909,  p.  609. 

'  Schmidt,  L.  E.:  Tlierap.  Gaz.,  September  1.5,  1909,  p.  609. 


GOXORRHEAL    THERAPY  493 

tion  of  temperature,  or  anorexia  may  also  occur.  A  slight  increase 
in  the  discharge  from  the  genital  tract  is  frequently  observed  for  a  few 
days  following  the  treatment. 

Vaccines 

Vaccines  or  bacterins  are  preparations  of  approximately  known 
numbers  of  dead,  gonococci  suspended  in  physiologic  salt  solution. 
Stock  or  autogenous  vaccines  may  be  employed,  and  the  consensus  of 
opinion  seems  to  favor  the  use  of  the  latter  when  they  are  obtainable. 
Autogenous  vaccines  are  especially  prepared  from  cultures  of  gono- 
cocci obtained  from  the  patient,  whereas  stock  vaccines  are  more 
easily  obtainable.  These  are  prepared  from  a  number  of  strains  of 
virulent  gonococci,  the  microorganisms  of  from  seven  to  ten  strains 
usually  being  employed.  The  cultures  are  grown  on  ascitic  agar,  and 
are  washed  off  with  normal  salt  solution  and  shaken  to  separate  the 
cocci  thoroughly  from  one  another.  The  suspension  is  then  sterilized 
with  heat  at  60°  C.  for  forty  minutes.  It  is  then  diluted  and  stand- 
ardized to  represent  a  definite  number  of  gonococci  to  the  cubic  centi- 
meter. Eyre  and  Stewart'  state  that  a  stock  vaccine,  prepared  from 
12  difTerent  strains  of  gonococci,  gives  results  only  slightly  inferior  to 
those  obtained  by  the  use  of  an  autogenous  vaccine.  To  overcome 
the  delay  necessary  in  obtaining  an  autogenous  vaccine  some  investi- 
gators begin  the  treatment  with  stock  vaccine  and  substitute  the  auto- 
genous vaccine  as  soon  as  the  latter  can  be  obtained.  Parke,  Davis 
and  Co.  prepare  a  stock  vaccine  in  three  strengths,  so  that  1  c.c. 
contains  respectively  20,000,000,  100,000,000.  and  500,000,000  bacteria 
per  cubic  centimeter.  The  i)liysiologic  salt  solution  used  in  this  work 
contains  0.2  per  cent,  of  trikresol  as  a  preservative.  It  is  sold  in 
hermetically  sealed  containers.  Vaccines  prepared  from  recently 
isolated  strains  are  more  toxic  than  when  the  microorganisms  have 
been  subcuUured  for  prolonged  periods. 

Technic  of  Administration. — The  teclinic  of  administration  is 
similar  to  thai  employed  for  the  serum. 

Opsonic  Index. — Most  authorities  concede  that  the  opsonic  index 
is  a  valual)le  guide  to  this  form  of  treatment,  and  should  be  employed 
whenever  possible.  On  the  other  hand,  the  method  of  determining 
the  opsonic  index  is  sonu'what  complicated,  and  unless  performed  by 
(jne  especially  skilled  in  its  use  is  of  little  or  no  value.  For  these 
rea.sons  some  investigatt)rs  have  depended  upon  the  clinical  symptoms 
as  a  guide  to  vaccine  therapy.  The  ju(hcious  use  of  bacterins  appears 
to  be  devoid  of  harmful  consequences,  and  for  this  reason,  if  it  is  not 

'  Kyrc,  .1.  W  .  II.,  :iw\  Sirwail,  B.  H.:   Luncot,  Lomloii.  .Inly  HI,  HIO'.I,  p.  7t>. 


494  GONORRHEA    IN    "WOMEN 

feasible  to  utilize  the  opsonic  index,  the  clinical  symptoms  may  be 
relied  upon  as  a  valuable  guide  in  determining  the  size,  number,  and 
frequency  of  the  dosage.  Eyre  and  Stewart^  state  that  in  chronic 
complicated  cases  in  which  the  gonococcus  alone  is  present,  and  in 
which  the  opsonic  index  cannot  be  obtained  as  frequently  as  is  desired, 
routine  injections  of  1,000,000  to  2,000,000  gonococci  every  three  to 
five  days  are  safe  and  satisfactory.  There  should  be  a  lapse  of  from 
five  to  seven  days  after  a  dose  of  5,000,000,  and  an  interval  of  eight  to 
ten  days  after  an  inoculation  of  10,000,000.  When  the  opsonic  index 
has  not  previously  been  determined,  small  doses  should  be  employed. 

Dosage.- — It  is  best  to  begin  with  a  comparatively  sniall  dose, 
5,000,000  to  20,000,000,  but  larger  doses  are  usually  required  before  a 
cure  is  effected.  Doses  are  usually  gradually  increased  until  one  is 
reached  that  produces  the  maximum  of  the  positive  phase  with  the 
minimum  of  the  negative  phase.  This  is  generally  about  20,000,000, 
although  it  may  reach  100,000,000  or  even  more.  A  second  injection 
should  be  administered  when  the  positive  phase  is  beginning  to  wane. 
The  number  of  doses  required  generally  varies  from  1  to  8,  4  or  5  being 
about  the  average,  with  intervals  between  the  doses  of  from  five  to 
ten  days.  As  a  general  rule,  in  chronic  cases  it  is  best  to  begin  with 
small  doses  and  gradually  to  increase  them  at  frequent  intervals.  The 
use  of  large  doses  is  more  dangerous  in  clironic  cases  than  in  acute 
attacks.  A  local  reaction  not  infrequently  follows  the  initial  injec- 
tion. Shropshire^  states  that  bacterins  not  only  sometimes  cause 
local  discomfort  at  the  site  of  the  injection,  but  may  be  followed  by 
pain,  swelling,  fever,  general  uneasiness,  malaise,  and  occasionally 
headaches.  These  manifestations  are  of  short  duration  and  of  mild 
grade.  In  most  cases  the  injection  is  followed  for  a  few  days  by  an 
increased  discharge.  Shropshire  reports  having  treated  111  cases 
of  acute  gonorrhea,  of  which  100  were  cured;  30  cases  of  arthritis, 
with  28  cures;  and  5  cases  of  gonococcemia,  all  of  which  were  cured. 
Thomas^  states  that  the  essential  point  to  be  carried  out  in  immuniz- 
ing, whether  by  vaccines  or  sera,  is  progressive  increase  in  dosage, 
beginning  with  the  minimum  and  steadily  increasing  until  tolerance  is 
estabUshed.  It  is  also  to  be  remembered  that  small  doses  at  prolonged 
intervals  are  prone  to  produce  anaphylaxis  and  hypersusceptibility. 
So,  too,  intolerance  can  be  produced  if  the  inoculations  are  not  too 
frequent,  but  are  too  large.     Bruck*'  holds  that  strong  reaction  and 

'  Eyre,  J.  W.  H.,  and  Stewart,  B.  H.:  Lancet,  London,  July  10,  1909,  p.  70. 
2  Shropshire,  C.  W.:  South.  Med.  Jour.,  May,  1911,  p.  352. 
'  Thomas,  B.  G. :  Jour.  Amer.  Med.  Assoc.,  January  22,  1910. 
<  Bruck:   Med.  Klinik,  1910,  No.  21. 


GONORRHEAL    THERAPY  495 

rise  of  temperature  are  necessary  for  active  inmiunization.  His 
arthigon  contains  20,000,000  gonococci  to  1  c.c.  He  injects  0.5,  1.0,  1.5 
and  2  c.c.  at  intervals  of  from  three  to  four  days.  Butler  and  Long^ 
state  that  in  their  series  the  dosage  varied  quite  markedly  in  different 
cases,  and  could  be  determined  only  for  each  individual  case  by  the 
immunizing  response  to  a  given  dose  as  indicated  by  the  opsonic  index. 
The  mininuim  dose  was  1,000,000,  and  the  maximum,  50,000,000. 
Stoner-  suggests  that  vaccines  should  be  employed  only  after  blood 
cultures  have  been  made  and  the  infecting  organism  identified  by  a 
skilled  bacteriologist,  or  in  local  infections  in  which  the  orgajiism  has 
been  isolated  and  identified,  or  in  cases  the  symptoms  of  which  are  so 
marked  that  a  mistake  in  diagnosis  is  beyond  a  possibihty. 

As  previously  stated,  markedly  beneficial  results  have  undoubtedly 
been  obtained  by  \accine  and  serum  therapy  in  certain  classes  of  cases 
— perhaps  most  notablj^  in  arthritis,  although  excellent  results  have 
also  been  secured  in  the  treatment  of  vulvovaginitis  of  children,  in 
systemic  manifestation,  and  in  certain  other  conditions.  Neverthe- 
less, more  experiments  with  serum  and  vaccine  therapy  are  required 
before  the  actual  value  and  scope  of  these  forms  of  treatment  can  posi- 
tively be  determined. 

'  Butler,  W.  .J.,  and  Long,  J.  P.:  III.  Med.  Jour.,  190S,  vol.  xiii,  p.  ."338. 
'  Stoner,  W.  H.:  Amer.  Jour.  Med.  Sci.,  1911,  new  series,  vol.  cxli,  p.  210. 


INDEX  OF  NAMES 


Abbott  (F.),  51 
Abbott  (G.  E.),  410 
Abel  (R.),  63,  64,  05,  66 
Abelaender,  41 
Abell,  328 
Abraham,  228 
Acton,  30 

Adams  (E.),  428,  432 
Adlcr,  99,  104,  232,  238 
Afrieanus  (C),  21 
Ahmann,  119 
Aichel  (O.),  377 
Alamatin,  347 
Albertin,  345 
Albrecht  (H.),  100,  358 
Albuca-sis,  21 
Alexanrlre,  272 
Alcxandron,  275 
Almagro,  326 
Almkvist  {}.),  467 
Alt,  404 

All  land,  407,  426,  428 
Amann,  345 
Amersbach,  106 
Amraon,  404 
Anderson,  328 
Anderson  (F.  J.),  486 
Andrews,  261,  404 

Anspaeh  (B.  M,),  197,  340,  342,  344,  354 
Apetz  (\V.),  124 
Arculanns  (J.),  22 
Ardern  (.1.),  21 
Areta;as,  18 

Arning  (E.),  40,  443,  446 
Aronstam,  401 
Arlhrnann,  108 
Arthur,  345 
Auahara,  456,  4()() 
Aseh,  221 
Ashby,  409 
Aubert,  40 
Aufrocht,  36 
Aufiiso,  73 

Aiilhorn,  283,  284,  346 
Auraiiil,  417 
Auspilz.  30 
Autlieuriot,  27 
32 


Auvray,  354 
Ayres  (W.),  79 


Baer,  68,  377,  395,  434 

Baer  (A.  N.),  426,  428 

Baer  (W.  S.),  435 

Baermann  (G.),  442,  443,  445,  446,  447 

Baginsky,  356,  387,  468 

Bailey,  132 

Baisch,  321 

Baldwin  (L.  G.),  306,  307,  346 

Baldy,  313 

Ballard  (J.),  25 

Ballenger,  487 

Balzer,  448,  460 

Bandler  (S.  W.),  119,  372 

Barbellion  (G.),  462 

Barcat,  278 

Bardoni,  450 

Bareggi,  39 

Barlow,  391 

Barnes  (F.),  404 

Barrie,  463 

Barrows,  253,  254,  255,  256 

Bartholinus,  90 

Bartholow  (P.),  451 

Baudron,  346 

Baunw--,  30 

Baux  (G.),  482 

Bayford,  26 

Beckett,  22 

Bchring,  482 

Bclhoinnie,  30,  31 

Bell  (B.),  27 

Bell  (R.  H.j,  339,  340,  342,  344,  346 

Bell  (W.  B.),  249 

Belleli,  39 

Bender,  441 

Bendig,  150 

Ben.'dictus  (A.),  23 

Benneeke,  427 

Beronstein,  409 

Berg  (H.  W.),  460 

Berger,  406 

Bernart,  165 

BiTiiliart,  462 


49S 


INDEX    OF   NAMES 


Bernutz,  28 
Bertrand,  450,  451 
Bettmann,  130 
Beyer,  252 
Bidwell  (L.  A.),  387 
Bier,  278,  432 

Bierhoff  (F.),  130,  139,  140,  154,  155,  1 
Bigart,  47 

Biglow  (M.  E.),  143 
Billard,  406 
Bland-Sutton,  112,  346 
Blaschko  (A.),  132,  141,  154 
Blokusewski,  175 
Bloodgood,  427,  466 
Blumer,  418,  436,  449 
Blyth  (W.),  476 
Bochart,  41 
•Bockhart,  37,  38 
Bockhart  (M.),  460 
Boese,  194 
Bogart  (G.  H.),  172 
Bokai,  36 
Boldt  (H.  J.),  240,  242,  244,  265,  277, 

297,  325,  327 
Bonifield  (C.  L.),  286 
Bonney  (C.  W.),  320,  321,  323,  324, 

331,  369 
Boord  (A.),  24 
Bormi^re,  402 
Bossi,  464 
Bouchard,  41 
Boursier,  346 

Bov^e  (J.  W.),  301,  315,  324,  325,  331, 
BowhiU,  6S 
Bradford,  431 
Braendle,  432 
Brande,  425 

Brassavolus  (M.),  23,  28 
Brehmer  (C),  420 
Bressel,  449 
Breton,  91 

Brettauer  (S.),  224,  362 
Brewis  (N.  T.),  346 
Brickner  (W.  M.),  320,  323,  324,  334 
Brieout  (C),  442,  447 
Bridgman,  488 
Bridgman  (0.),  127 
Brieux,  165 
Brin  (H.),  327 
Brindeau,  245 
Brose,  127,  202,  206,  223 
Brose  (P.),  359 

Brothers  (A.),  303,  304,  306,  307 
Brown  (G.  V.  A.),  303,  306 


Brown  (H.  A.),  126 

Brown  (L.  R.),  292 

Bruck  (C),  81 

Bruck,  494 

Brunei,  228 

Brtinschke,  202,  205,  206 

Bruschke,  383,  384,  445 

Bryan  (C.  W.  G.),  490 

Buji\-id,  436,  467 

BuUeyn  (W.),  24 

Bulhtt,  328 

Bumm  (E.),  34,  36,  38,  39,  42,  46,  61,  63, 
65,  73,  75,  76,  120,  127,  202,  206,  216, 
217,  233,  2.59,  264,  273,  275,  283,  356,  369, 
370 

Bumstead,  30 

Bundy,  367 

Burchardt,  415 

Burckhardt,  367 

Burdett,  407 

Burger,  251 

Bui-nam  (C.  F.),  317 

Bui-rage,  346 

Buschke,  444 

Butler  (W.  J.),  80,  487,  495 

Buttner,  99 

Byers  (W.  G.  M.),  415 


Cabot,  130 

Cabot  (F.),  461 

Cabot  (H.),  393 

Cajal  (P.  R.),  273 

Camanus  (M.),  23 

Cameron,  235 

Campbell,  416 

Campbell  (J.),  462 

Campona,  39 

Cannbne,  354 

Caput,  312,  335,  344,  354 

Cardile,  451 

Carlslaw,  461 

Carmichael  (E.  S.),  289,  297,  300 

Carmichael  (H.),  25 

Caron,  27,  28 

Carpenter  (G.),  386,  387 

Carrell  (W.  B.),  334 

Cartledge,  328 

Cassel,  466,  467 

Cathelin  (F.),  339,  341,  343,  346,  351 

Cause,  416 

Celler,  78,  79 

Celsus,  18,  19 

Cermisone  (A.),  21,  22 


IXDEX    OF   NAMES 


499 


Ceme,  327 

Chabry,  349 

ChaUer,  320,  327 

Chameron,  39 

Chappie  (H.),  3sl 

Chaput,  320,  332 

Charrot,  462 

Chartres,  404 

Chartres  (E.t,  407,  420;  424 

Chauffard  (A.),  442,  443,  445,  446,  447 

Chavassa  (Mj,  319 

Cheatham,  415 

Cheron,  277 

Cherrel  (F.),  423 

Chevassu,  332 

Chevket,  443 

Chej'ne,  36 

Chiaiso,  451 

Chick  (H.),  471,  476 

Chipault,  326 

Cholzow  (B.  X.),  419 

Chornagiiboffna.  44S 

Christian  (H.  M.),  142,  164 

Christmasis,  463 

Chrobak,  481 

Clado,  447 

Clark  (J.  B.),  130,  42K,  471,  474,  4S1 

Clark  (J.  G.),  127,  240,  262,  292,  299,  303, 

307,  315,  333 
Clark  (S.  M.  Dj,  317 
Clossius,  27 

Clowes  (C.  H.  A.),  83,  84 
Coffey  (Robert  C),  294 
Cohen  (H.),  403 
Cohn,  124,  404 

Cole  (R.  I.),  423,  424,  427,  430,  438,  453 
Collard,  316 
Collingsworth,  404 
Collins,  404 

Comby  (.!.),  356,  359,  387 
Cones  (W.  P.),  363 
Coombc  (R.),  331 
Cooper  (J.  B.),  486 
Cope  (H.  R.),  334 
Coplin,  169 
Cotte,  320,  327 
Cotton,  377,  383 
Councilman,  438,  439 
Cragin  (E.  B.),  256,  372,  4.S6,  487 
Cramer,  407 
Cred6,  25,  407,  409 
Crevelli,  41 
Crompton  (Si,  104 
Oos,  462 


Crosby  (D.),  400,  402 

Cseri,  41 

Cullen  (T.  S.),  91,  94,  96,  231,   234,  245, 

299,  363,  364 
Cumston  (C.  G.),  356,  461 
Currier,  384 

Gushing  (H.  W.),  329,  356,  359 
Cutaneus  (J.),  22 
Cutler,  401 


Dabney,  437 

Dannreuther,  206 

Darier,  408 

Dartigues,  92 

Dauber,  409,  480 

Da\idson,  434 

Davidson  (A.  J.),  434 

Davis  (A.  B.),  257,  262 

Davis  (E.  P.),  127,  313 

Davis  (M.  E.),  170 

Dawbarn  (R.  H.  M.),  485 

de  Camboulas  (B.),  317 

de  Cassis  (V.),  28 

de  Cauliaco  (G.),  21 

de  Christmas,  74 

de  Damany,  442,  445,  446 

de  Forest,  154,  155,  401 

de  Gaddesden  (J.),  21 

do  Landau,  30 

de  Pezzer,  41 

de  Rothencourt  (J.),  24 

de  Rouville,  282,  312,  313 

de  Schweinitz  (G.  E.),  403,  410,  411,  412. 

413,  414 
de  Sineity,  41 
De  Stella,  402 
de  Taranta  (V.),  22 
de  Tornamira  (J.),  22 
de  Velde  (V.),  48 
de  Vigol  (T.),  23 
Deaver  (J.  B.),  301 
Debierre  (L.),  408 
Decousser,  466 
Deidier,  31 
Delbet  (P.),  336,  347 
Delore,  347 
Denis,  461 
Dennis  (\V.  A.),  465 
Derby  (CS),  471,  475,  480,  481,  484 
Desruelles,  27 

Deutschmann,  407,  408,  426 
Devaux,  24 
Devergie,  27 


500 


INDEX    OF    NAMES 


Diaz,  249 

Di  Christina,  297 

DickiiLson  (R.  L.),  288,  299 

Diday,  30,  402 

Dieulafoy  (G.),  419,  422,  423,  43(5,  444,  449, 

451,  463 
Doderlein,  119,  122,  213,  21.5,  223,  358 
Dodge  (W.  T.),  457 
Dodson,  28 
Doleris  (P.),  383 
Donne,  31 

Doran  (A.),  109,  112,  361 
Dorland  (W.  A.  N.),  405 
Douglas  (S.  R.),  447 
Dowd,  356,  377,  387,  454,  461 
Dreier,  150 
Drenkhahn,  230 
Drebet,  317 
Dubendorfer  (E.),  214 
Dubreuilh,  201 
Duelling  (J.),  434 
Dudgeon,  453 
Dudley,  329 

Dudley  (A.  P.),  303,  306 
Dudley  (E.  C),  244 
Dufaux,  186 
Dufour,  20 
Dlihrssen,  308 
Dukelski,  376 
Duncan,  26,  487 
Dunn,  86 
Durand,  434 
During,  141 
Durkee,  30 
Duval,  69,  73 
Duyon,  30 
Dyer  (I.),  170 


Eberhard,  127 
Echols  (C.  M.),  332 
Ecklund,  37 
Edgar  (J.  C),  481 
Edwards  (C),  25 
Ehrcnfield,  484 
Ehrlich,  36 
Eisenberg  (J.),  45 
Eisenmann,  27,  28,  118 
Eising  (E.  H.),  81,  85 
EUerbroeck,  100 
Ellis,  26 
Elser,  61,  77 
Ellze,  250 
Emery,  468 


Emley,  132 

Emmet,  239 

Empiricus,  18 

Epstein,  377,  385 

Erb,  130 

Esch,  296 

Eschbaum,  39 

Escherich,  408 

Esman,  481 

Evans,  27 

Evans  (T.  G.  C),  331 

Eulenberg,  462 

Eyre,  416 

Eyre  (J.  W.  H.),  493,  494 


Fabre,  277 

Fabricius,  322,  327 

Fabry,  202,  205,  206,  223 

Fallopius  (G.),  23 

Farbach,  491 

Fassano,  354 

Faure-Beaulieu,  419,  423,  450 

Fehhng  (H.),  363 

Feistmantel,  180 

Fenger,  71,  427,  435.  436 

Fenwick,  329 

Fenwick  (R.  G.),  408,  426 

Ferarri,  41 

Ferguson,  253 

Ferroni  (E.),  317 

Fett,  2.50,  251 

Fiessinger  (N.),  442,  443,  445,  446,  447 

Figueras,  423 

Findley,  330,  360 

Findley  (P.),  .381 

Finger,  25,  31,  49,  74,  79,  85,  124,  141,  205, 

208,  217 
Finkelstein,  36 
Firth,  471 
Fish  (S.),  24 
Fisher  (A.),  451 
Fisher  (J.  M.),  278,  319,  333 
Fiske,  135 
Fiske  (C.  N.),  137 
Flatau,  149 
Flatau  (S.),  2.50,  277 
Flcxner  (S.),  77 
Flick  (L.  F.I,  1.50 
Forchheimer,  130 
Foulerton  (A.  G.  R.),  369 
Fournier,  30,  140,  156,  165 
Francais,  347 
Francisco,  404 


INDEX    OF    NAMES 


501 


Franco  (E.  E.),  458 

Frank,  175 

Frank  (L.),  329 

Frank  (R.  T.),  100 

Friinkel,  40,  41,  31t),  317,  347 

Frankenstein,  250 

Franque,  229,  252,  484 

Frederic,  127,  262 

Frescoln  (L.  D.),  415 

Freund  (H.),  275,  278 

Friedlander,  60,  491 

Friedrich,  433 

Fritsch  (H.),  347 

Froin,  442 

Frosch,  78 

Fruhin.sholz,  367 

Funck-Brentano  (L.),  128 

Funke,  347 

Fiirbringcr  (P.),  127,  460,  463 


G.^JFKY,  36 

Galen,  17,  18 

Galewski,  79 

Galewsky,  42 

Galezovvski,  414 

Galliard,  320,  332 

Galvagno  (P.),  356,  357,  386,  387 

Garceau,  208 

Gardner,  83,  84 

Gardner  (J.  A.),  330 

Geget,  273 

Geigel  (A.),  30,  32 

Gellhorn  (G.),  250,  251,  286 

Gennerich,  485 

Genter  (G.),  110 

Geraghty,  453 

Geraud  (H.),  450,  451 

Gerrish,  131 

Gerster  (A.  G.),  458 

Gersuny,  286 

Ghika,  442,  447 

Ghon  (A.J,  71,  78,  436,  440 

Gilison  (B.),  24 

Gicerin,  207 

Gigorieff,  289 

Giles  (A.  E.),  28,  288,  300,  303,  304,  305 

307,  308,  313,  314 
Giorgi,  316 
Giovannini,  41 
Godart,  112,  317 
Goopel,  364 
Coctz  (.].  (•,.).  24 
GdldlHTK,  124 


Cioldschmidt,  367 

CJolesceano,  404 

Gonin,  404 

(ionsolin,  320 

(Joodnian,  432 

Goodman  (C),  356,  357 

Ciordon,  86 

Gossct,  347 

Goth,  281 

Gottschalk  (S.),  97,  336 

fiougerot,  443 

Gould  (C.  W.),  476,  478,  482,  483 

GouUioud,  347 

Goupil,  28 

Gradl  (H.),  269 

Gradwohl  (R.  B.  H.),  81,  S3 

(■ram,  55,  56,  57 

Grandin,  127 

Green,  25 

Greene,  408 

( irekow,  358 

Ch-iffith  (W.  S.  A.),  282 

Griffon,  409,  426 

Groenou  (W.),  404,  413 

Gros  (O.),  479 

Grosse  (M.  A.),  333 

Grosz  (S.),  448 

Cinibbs,  134 

(irubor,  471 

Gucirel,  407 

tiuerola,  404 

Giiiard  (F.  P.),  180 

( iuicciardi  (G.),  342,  347 

( liiiteras  (R.),  46,  157,  432 

Gunther,  57 

Gurd  (F.  B.),  71,  78,  80,  102,  107.  110. 

3()7.  368,  369,  371 
Gurvich,  437,  438 
(Juthrie,  262 
Guyomor  (D.),  25,  30 
Guyot,  431 


IIa.mi,  37,  404,  409 
IIal)erda,  50 
Hacker,  118 
llagewisch,  25 
Hagner  (F.  R.),  457 
Ilalban,  289 
Hales,  25,  27 
Hali'iix,  335 
Hullc,  204,  448 
ll.dli.r.  31,  35 
II.MiMilhin  iB.  \V.),  .381. 


502 


INDEX    OF    NAMES 


Hamm  (A.),  442 

Haimes,  478 

Harmsen,  47 

Harp6th;348 

Harrar  (J.  A.),  128,  367,  370 

Harrigan  (A.  H.),  257 

Harrington  (C),  478,  483 

Harris  (N.),  387,  437,  466,  477 

Harrison  (L.  W.),  26,  46,  71,  77.  125,  248, 

461 
Harrow  (J.  A.),  257 
Hartmann,  301 
Hartmann  (C.  R.),  348 
Hartmann  (H.),  339,  348 
Harwood,  160 
Hasciiard  (P.),  24 
Hasenfeld,  250 
Haskell,  466 
Haslung  (O.),  443 
Hatfield  (M.  P.),  356,  387 
Haushalter,  407,  409,  426,  428,  463 
Hausmann,  175,  402,  404 
Hebuin,  131 

Hecker,  409 

Hedley  (J.  P.),  348 

Heerfort,  443 

Heger-Gilbert,  59 

Heiligenthal,  431 

Heilman,  428 

Heilmann  (W.  J.),  365 

Heiman,  61,  68,  73 

Heinsius,  490 

Hellendall  (H.),  405,  409 

Heller,  440 

Henkel,  281 

Hemieguy,  41 

Hennig,  94,  361 

Henry  (R.  B.),  176,  177 

Herandez,  27 

Herff,  313,  348,  481 

Herodotus,  17,  18 

Herzog  (M.),  446 

Hewlett,  476 

Heymann,  107,  261 

Heynemann,  262 

Heys  (W.),  207 

Hilbert,  416 

Hildebrand,  431 

HiU  (C.  A.),  317 

Himmelheber,  419 

Hippociates,  18,  172 

Hirschberg,  37,  402.  404 

Hirsh  (J.),  432 

Hirst,  348 


Hirtz,  433 

Hiss  (P.  H.),  79 

Hitschmann,  99,  104,  232,  238 

Hock  (H.),  420,  425 

Hodara  (H.),  419,  443,  448 

Hoeck,  406,  408,  420,  426 

Hoelder,  30 

Hoffman,  424,  439 

Hofman,  210 

Hofmeier,  274,  275,  278,  409 

Hogan,  27 

Hogg  (J.),  25 

Holder,  401 

Holloway  (T.  B.).  413 

Holt,  376,  385,  427 

Helton,  129 

Holzback,  299 

Horrmann,  250 

Horwitz,  449,  466 

Hosford  (J.  S.),  414 

Howard,  27 

Howell  (W.  H.),  453 

Huard,  316 

Huber,  150,  356,  395 

Huff,  179 

Huguier,  188,  20L  207 

Hiilke.  25 

Huraston  (W.  H.),  296 

Hunner  (G.  L.).  206,  211,  229,  356,  387 

Hunter  (Sir  J.),  26,  28 

Huntoon,  61,  77 

Huras  (H.),  325 

Hurdon  (E.),  104,  301 

Hyde  (C.  R.),  261,  263,  285.  301,  306 

Hymen  (S.  M.),  401 


ICARD,  40 

lUman,  487 

Imlach,  336 

IngaUs,  330 

Irons  (E.),  83,  84,  421,  422,  444 

Isnardi,  451 

Ivens,  132 

Izzet,  419,  443 


Jacob  (A.),  25 

Jacobi,  433 

Jacobs,  278,  348 

Jacquet,  434,  442,  443,  447 

Jad.assohn,  85,  115,  125,  397,  420 

Jaeger.  434 

Janet  (J.),  469 


INDEX    OF    NAMES 


503 


Janeway  (E.  G.),  326 

Jardine  (R.),  404 

Jayle  fF.),  249 

Jeanselme  (E.),  442,  447 

Jesionek,  395,  400 

Jewett  (H.),  303,  306,  307 

Jieinsky  (J.  R.),  451 

Joanno\^cs,  102 

Jochmann,  423 

Johnston-Lavis  (H.  J.),  450,  451 

Jordan  (A.).  393,  429 

Joseph,  106 

Judet,  311 

Jugens,  399 

Jullien,  30,  395,  398,  426 

Jiindell,  466 

Jung,  250,  379 

Juvenal,  18,  19 


Kaan  (G.  W.),  127 

Kadigrobow  (B.  A.),  342,  349 

Kalt,  411 

Kammerer,  40 . 

Kanka^o^^lsch,  463 

Karo  (W.),  400 

Kauffniann,  342,  349 

Kauniheimer,  385 

Kawawoyc  (M.),  298 

Kean  (J.  R.),  132,  135,  137,  138,  160 

Keene  (F.  E.),  99,  232,  238 

Kehrer,  251,  286 

Keifer,  65 

Keilmann,  250,  251 

Keillor,  250,  251,  252 

Kelly  (II.  A.),  151,  151,  102,  207,  249,  299, 

301,  311,460,482 
Kendal  (A.  I.),  486 
Kenwood,  476 
Kerr,  137 

Kerr  (J.  W.),  168,  403 
Kerr  (J.  M.  M.),  300 
Keyes  (E.  L.),  57,  118,  125,  130 
Keyser,  39 
Kieler  (K.),  419 

Kienbock,  429,  461,  462,  463,  4  ili 
Kimball.  376,  377,  380,  383,  401.  420,  421, 

428,  435 
Kircher  (A.),  31 
Kirslen,  252 
Klebs,  31 
Klein.  349 
Kleinhaus,  109,  U2 
Kloin\v;ichler,  92 


Knaack,  53 

Knauer,  289 

Knies,  405 

Knorr  (R.),  .391,  4.V2 

Koark  (B.  H.),  443 

Koblanck,  377 

Koch,  31,  470 

Kohler  (R.),  81 

Kolischer  (G.),  453 

Kolle,  78 

Koltz,  360 

Konigstein,  37 

Konstantinides  (G.),  299 

Kopfstein,  404 

Koplik,  356,  376,  385,  387,  399 

Korte,  332 

Koster  (H.),  439 

Kouchner  (M.),  273 

Krafft-Ebing,  378 

Krast,  399 

Kratter,  59 

Kries,  40 

Krompeeher,  111 

Kroner,  40,  404 

Kninig,  85,  107,  214,  261,  366,  3()8,  369,  470, 

482,  483,  484 
Krouse,  37,  74.  416,  419,  451 
Krusen,  318 
Kuhn,  221 
Kuhn  (J.  F.),  277 
Kulb.s,  437. 
Kuniita,  455 
Kiimmell  (H.),  391 
Kurka  (A.),  415 
Kuster,  461 
Kutscher,  477 


L.\BUSQrixE  (R.),  214 
Lacroix,  17 
Lambert,  317 

Lamouroux  (H.  G.  A.),  321,  324,  337,  338 
Lang,  449,  466 
Langlebert,  30,  37 
Lanz,  54 
,  Lanz.  (A.),  118,  119 
La.ser,  206 
Latzko,  320 

Launois  (P.  E.),  412,  447 
Lawrence  (W.),  25 
Lazcar,  450,  4.")2 
Le  Bon,  27 
Le  Moiiiol,  336 
I.c  Nouene,  364 


504 


INDEX    OF   NAMES 


Le  Pileur,  146 

Lea,  253,  255,  3o9 

Lebert,  30 

Lecky,  150 

Lecour,  448 

Ledbetter,  176,  178 

Ledermann  (R.),  58 

Lee  (H.),  29 

Leede,  420 

Leedham-Gieen,  401 

Legrain,  42 

Legueu,  302,  319,  326,  349 

Lehr  (L.  C),  457 

Leipmann,  234 

Leistikow,  37,  74 

Leith,  328 

Lejars  (F.),  320,  322,  336,  337,  344,  349 

Lenehan  (W.),  122 

Lenfrancus,  21 

Lenkei,  279 

Leopold,  367,  402,  409,  480 

L'Esperance  (O.  R.  T.),  393 

Lesser,  141,  462 

Leszczynsky,  53 

Lewars  (P.),  336 

Lewers,  350 

Lewicki,  250 

Lewis  (B.),  454,  456,  457,  459 

Leyden,  399,  437,  463,  468 

Lhermite,  483 

Libman,  78,  79 

Lindermann,  408,  425 

Lindholm,  390 

Linglesheim,  61 

Link  (G.),  335 

Lipschiitz,  67 

Lipsius,  18 

Litchfield,  132 

Little  (E.  G.),  447 

Litzenberg,  317 

Lobenstine,  128 

Lock  (N.  F.),  261 

Lockyer,  395 

Loewy  (R.),  249 

Lofaro  (F.),  421,  425 

LoflHer,  49,  50,  74 

Lohnstein,  486 

Lomer,  367 

London  (J.),  85 

Long  (T.  P.),  80,  495 

Lorat-Jacob,  462 

Loven  (G.),  356 

Lovett  (R.  W.),  428 

Lovrich  (J.),  285 


Lucas  (R.  C),  408,  426,  427 
Luczny,  202,  206 
Lundstroem,  40 
Lustgarten,  41,  75 
Luther,  123 
Luther  (J.  W.),  132 


Macaignb,  433 

Macdonald  (A.),  34,  485 

Macfadyen,  471 

Mackenrodt,  286 

Mackenzie  (W.),  25 

MacLaren,  326 

MacMonagle,  330 

MacMunn  (J.),  124 

Mc.\rthur  (A.  N.),  286 

McCann    (F.  J.),  223,  355 

McCrae,  431 

McDonagh  (J.  E.),  120 

McDonald,  369,  437 

McFarland  (J.),  SO 

McGlinn,  333 

Mcllroy,  289,  298,  350 

McKee,  53,  415 

McNeil  (A.),  81 

McVeigh,  396 

Madlener  (M,),  246 

Magninus,  22 

Maillard,  339,  350 

Maimonides,  IS 

Maizer,  317 

Malherbe  (H.),  401,  442,  447 

Mandl,  216 

Mann,  319,  329 

Mannaberg,  41,  75 

Manton  (W.  P.),  303,  306,  307,  464 

Marchand,  102 

Marchiafava,  39 

Marchildon  (J.  W.),  424 

Marcuse  (B.),  455,  458 

Margan,  419 

Marini  (G.),  437,  439 

Markheim,  427 

Markoe  (J.  W.),  201 

Marquis  (E.),  484 

Marschalko,  102 

Marshall  (C.  R.),  470,  480,  484 

Marshall  (F.  A.  F.),  297,  300,  479 

Martial,  18,  19 

Martin,  30,  31,  228,  286,  319,  325,  350,  360, 

361 
Martin  (A.),  285,  355 
Martin  (C,  J.),  303,  471,  476 


INDEX    OF    NAMES 


505 


Martin  iF.  H.),  263,  298 

Martin  (.W.  B.),  63,  68,  72,  78 

Martineau,  41 

Martiniere,  24 

Marx,  384.  387 

Mary  (A.),  319,  321 

Mascarenhas,  327 

Maslowsky,  366 

Maus  (L.  M.),  178 

Mayo  (C.  H.),  317 

Mayou,  77.  403.  404,  407 

Mazza,  4.50,  4.52 

Meakins,  81 

Meir,  248 

Mei.senbaph  (R.  O.),  435 

Mejia,  3.56,  387 

Melchoir,  390 

Mendelsohn,  460 

Menge  (K),  8.5,  96,  107,  111,  112.  121,  130, 
141,  1.54,  202,  206,  214,  215,  223,  228,  2.59, 
261,  264,  273,  278,  370,  383,  482 

Mercade,  252,  254 

Merdervoort  (P.),  355 

Mestsehersky  (G.),  448 

Mesue  (J.),  21 

Meyer,  65 

Meyer  (F.),  303,  467 

Meyer-Delius,  443,  446 

Michaclis,  .30 

Michel,  3.50.  419 

Miller,  261,  263,  416 

Miller  (J.  W.),  10.3,  107 

Milton,  .30 

Mitchell  (O.  \V.  II.),  4S4 

Mittehnann  (C),  99,  100 

Miyata,  461 

Mock,  2.52 

Mocquot,  2.52 

Moller,  146,  173 

Molt.schanoff,  75,  461 

-Moncarvo,  409 

Moiitjsomery  (E.  E.),  3.50 

Moorhead  (G.  I.),  419 

Mora.v,  408 

Morel,  .351 

MorRcaslein,  37.S 

Morris  (L.  G.I,  28t) 

Morri.s  (U.  T.l,  271 

Morrison,  24 

Morrow  (L.),  127,  4.S8 

Morrow  (P.  A.),  131.  143.  145,  171 

Mortdn  (H.  N.),  120 

Mortz  (B.),  461 

Moses,  20 


Miiller,  30,  SO,  486 
Mummery,  137,  179 
Munson,  133,  136 


XaK-a-Abe,  66 

Xanu,  351 

Xassauer,  229 

Xatvig,  369 

Xeave  (E.  F.  M.),  479,  480,  484 

Xeisser  (A.),  25,  34,  35,  36.  50,  .58,  124,  126 

127,  130,  141.  154,  165,  175.  263,  404 
Nelson,  28 
Neuendorf!  iF.),  460 
Neumann,  366 
Ne\-ins,  161 
Newberry,  39 
Newell  (F.  S.),  487 
Nicolas,  434 

NicoU  (H.  K.),  471,  481,  48.5,  486 
NicoUe,  57 
Nieden,  404 
Nikolaysen,  75 
Nixon  (P.  I.),  452,  4.53,  4.59 
Nobl,  434 

Noble,  127,  252,  256,  262 
Noeggerath  (E.),  25,  ,32,  33,  34,  120,  131, 

261 
Norris  (C.  C.),  99,  127,  232,  238,  299,  303, 

307,  333,  363,  387 
Norris  (G.  W.),  436 
Norris  (K.  G.),  262 
Northrup,  356,  427 
Northrup  (,W.),  .387 
Nowak.  .58 
Nutthaft,  124 


Oastler  (F.  R.),  270 
Oke  (W.  S.),  25 
Oleson,  329 
OLshausen,  281,  315 
O'Neil  (R.  F.),  S4 
Opitz,  109,  234 
Opponheimer,  40,  80 
Oriipski,  443,  448 
Orr,  279 

Ortenau  (G.),  464 
Ortner,  351 
Osman,  419,  443 
Otis,  30 
Otto,  477 


506 


INDEX    OF   NAMES 


Padula,  423 

J'aldrock,  452 

Palmer,  26 

Paltauf,  466 

Paltrock,  57 

Panas,  415 

Pankow,  214,  215,  201,  302 

Pappenheim,  51,  54 

Paquy,  351 

Paracelsus,  23 

Park,  64,  78 

Pasteur,  31 

Patek,  312 

Paul,  40,  470,  482 

Pauli,  30 

Paulsen,  407,  426,  445,  449 

Payr,  340 

Peham,  250,  251,  252 

Pellagatti,  106 

Penrose  (C.  B.),  356 

Perrin,  197,  379,  383 

Pes,  416 

Peterkin  (G.  S.),  162 

Peterson,  41 

Peterson  (R.),  288 

Petit,  394 

Petronius,  19,  24 

Peuch,  326 

Pfeiffer,  60,  70 

Pfeiffer  (H.),  78 

Pfeiffer  (R.),  78 

Pfister  (E.),  173 

Phalen  (J.  M.),  180 

Phelps  (E.  B.),  486 

Piche\an,  394 

PiersoQ,  351 

Pilz,  369 

Pinard,  351,  354 

Pinto  (G.),  40 

Piogey,  172 

Pitzman  (M.),  479,  482 

Placidas,  18 

Plauchu  (E.),  128 

Pliny,  18 

Proksch  (J.  K.),  17 

Plomley,  376 

Podrcs,  41 

Poirier,  351 

Polak  (J.  O.),  221,  226,  240,  286,  290,  296, 

299,  304,  306,  307,  351,  374,  484 
Polando,  219 
Polano,  250,  251 
Politzer,  407,  463 
Polk,  285,  286 


Pollack,  370,  378,  379,  380 

Pollock  (C.  E.),  46,  71,  77,  125,  248,  461 

Poncet,  335 

Porosz,  175,  484 

Posner,  106 

Post  (W.  E.),  471,  481,  485,  486 

Pott,  376,  378 

Potzler,  124 

Pouey,  42 

Powell,  161 

Powers  (C.  A.),  465 

Pozzi  (S.),  127,  262,  285,  286,  351,  355 

Praeger  (J.),  339,  352 

Preuschen,  94 

Price,  127,  262 

Price  (M.),  329 

Prochaska,  416,  419,  452 

Prochownick  (L.),  275,  278,  280 

Propertius,  19 

Proskauer,  471 

Proust,  327 

Prowe,  150,  241 

Pryor  (W.  R.),  206 

Puckner  (W.  A.),  486 

Pugh  (W.  S.),  443,  444 

Pugnat,  297 

Pyri,  484 


QUELLMALZ  (G.  S.),  24 

Qugnu,  311 


Rassegna,  94 

Rathburn,  165 

Rauzier,  42 

Ravogli,  455,  461 

Raymond,  179 

Rebaudi,  316 

Recio  (A.),  85,  491 

Reder,  30 

Reed,  300 

Reinhard,  465 

Reismeyer  (L.  T.),  331 

Reiter,  84 

Rendu,  448 

Report  of  American  Public  Health  Associa- 
tion, 147 

Report  of  the  Chicago  Vice  Commission, 
1911,    131,  146,  164 

Report  of  Committee  of  Seven,  128,  129, 
133,  234 

Report  of  the  Mortality  Statistics,  Wash- 
ington, 1912,  126 


IXDEX    OF    NAMES 


507 


Report  of  the  Xew  York  Medical  Associa- 
tion, 129 

Report  of  the  Royal  Commission  on  the 
Blind,  1889,  128 

Report  of  the  W'asliington  State  Medical 
Association,  129 

Resnikow,  426 

Rey  (C),  419 

Reyling,  404,  415 

RejTnond  (E.j,  339,  347,  34s 

Rhanges,  21 

Ribbert,  289 

Richardson  (E.  H.),  HO,  294 

Richelot,  276 

Ricord  (P.).  27,  28,  34,  213,  436 

Riedal,  471 

Ries  (E.),  109,  342,  352 

Risch,  252 

Ritter,  27 

Rivaud-Landrau,  404 

Rivet  (L.),  442,  447 

Roark  (B.  H.),  446.  488 

Robb  (H.),  127,  262,  302,  307,  335 

Robert,  30,  447 

Robert  (E.J,  442 

Roberts  (J.),  492 

Robin,  376 

Robin  (A.),  443 

Robins  (C.  R.),  257,  303,  304 

Rochet,  326 

Rockhffe  (\V.  C),  408 

Rogers  (J.),  74,  316 

RoUeston,  3.56 

Rollet,  417 

Romanowsky  (D.),  52 

Romniceanu,  376 

Rosenfcld,  461 

Rosenthal,  442 

Rosiaski,  399,  401 

RoHolimes,  30 

Ross,  343,  355 

Rossi  nsky,  363 

Rost  (R.),  443 

Rosthorn,  106,  214,  302 

Rost-Kiel  (V.),  443 

Roth  (V.),  447 

Hothrock  (.1.  L.),  424 

Kolky  (K.),  419 

llouffart,  342,  352 

Roux  «;.),  .54 

Rovsing,  42 

Hiiliinstein  (H.),  289 

I  {inker,  36 

Hue,  .331 


Ruge,  231 
Ruge  (C),  96 
Runge,  104,  409 
Ryall  (J.),  25 


Sabatier,  468 

Saint-Marc,  443 

Sakaguchi  (Y.),  85 

SaUsbury  (J.  H.),  35 

Salomon,  462 

Sampson  (J.  A.),  253,  254,  352,  355,  454 

Sanger,  19,  22,  130,  213,  216,  223,  230,  352. 

355,  367,  368,  384 
Sanger  (W.  W.),  127,  131 
Sarfert,  468 
Saunders  (J.  C),  24 
Sax,  52,  124 
Scahnger,  19 
Scanzoni,  360 
Schaeffer,  61,  79 
Schanz,  80 
Schtin,  199 
Schenck  (P.  S.),  1,58 
Schener,  380 
Schiess,  485 
Schiffman,  312 
Schiller,  194 

Schindler  (C),  230,  248,  270,  489 
Schlagenhaiifer  (F.),  71,  431),  440 
Schmidt,  460 
Schmidt  (A.),  24,  490 
Sclmiidt  (L.  E.),  82,  83,  492 
Schneider,  424 
Schnurmans-Stekhoven,  42 
Schoenberg,  204 
Schottmiiller,  367 
Schramm,  361 
Scribonius,  IS 

Schridde,  101,  102,  106,  111,  Jill 
SchuUer,  207 
Schultz,  206 
vSchultze,  464 
Schumburg,  471 
Schwartz  (E.),  1.32 
Schwartz  (H.  J.),  81,  83,  84 
Sclpiades,  480 
Scotus  (M.),  21 
Sears,  437,  438 
Sebillcau,  387 
Sederl,  78 

Seelig  (M.  G.),  476,  478,  482,  483 
Seiffert,  385 
Scippcl.  37S 


508 


INDEX    OF    NAMES 


Spippel  (C.  P.),  382 

Seligmann,  471 

Selle  (C.  G.),  24 

Sellei,  452,  458 

Sellenew,  463 

Sellheim,  278 

Sequeira  (J.  H.),  442,  445 

Serapion,  21 

Sevediaur,  17 

Sever  (J.  W.),  428 

Shropshire  (C.  W.),  494 

Shumburg,  484 

Shumway,  416 

Sichel  (C.  C),  334 

Sidler-Hugenin,  415 

Sieber,  275 

Sigaui-d,  424 

Sigmund,  30 

Silvestrini,  444 

Simmons  (W.),  24 

Simon,  28 

Simount  (G.  J.  P.),  339 

Simpson,  274,  283,  303 

Simpson  (P.  E.),  443,  446,  447 

Sina  (E.),  21 

Sinclair  (N.  J.),  36 

Sippel  (A.),  209 

Sireday,  47,  352 

Skene,  207,  211 

Skutsch,  286,  377,  383 

Slachow,  150  , 

Slack  (F.  H.),  485 

Slatter,  37 

Slingenberg  (B.),  85,  491 

Smith  (A.  L.),  330 

Smith  (J.  T.),  370,  422,  440,  452 

Smith  (R.  R.),  198 

Sncgireff  (G.),  270 

Sncguireff  (V.  T.),  311 

Sobotka,  409 

Sonnenfeld,  192 

Souplet,  460 

Souv(5,  298 

Sowinsky  (S.  W.),  419 

Spooner,  30 

Standish,  411 

Stanislawsky,  442,  447 

Stark,  352 

Stein  (A.),  365 

Steinschneider,  42,  61,  79,  202,  206,  223,  465 

Stelhvagen  (T.  C),  487 

Stephenson  (S.),  24,  131,  367,  369,  402,  403, 

404,  405,  406,  407,  408,  411,  412,  420,  424, 

426,  467,  479,  480,  481,  485 


Sternberg,  39 
Sternberg  (A.  J.),  85 
Stevens,  355,  420 
Stevens  (A.  A.),  485 
Stevens  (E.  W.),  407,  424 
Stewart,  416 

Stewart  (B.  H.),  493,  494 
Stewart  (L.  P.),  455 
Stockel,  250 
Stojanschoff,  461 
Stokes  (J.  E.),  296 
Stolz,  214,  352 
Stone,  279,  286,  300,  369 
Stoner,  487,  495 
Stoner  (A.  P.),  338 
Storer,  146,  353 
Stoyantchoff,  461 
Straganoff,  355 
Stratz,  353 
Strong,  466 
Strzeminski,  377 
Sturgis,  424 
Suker  (G.  P.),  406 
Summers,  311 
Swartz,  132 
Swediaur,  26 
Swift.  (H.),  443 
Swinburne  (G.  K.),  82 
Sydenham,  24 
Szasz,  364 


Tait  (L.),  42,  336 

Tandler,  181 

Tarnowsky,  30 

Taussig  (P.  J.),  208,  211,  367,  369,  464 

Taylor,  106,  353 

Taylor  (H.  S.),  404 

Testu,  301 

Thaler  (H.),  283 

Thalhimer  (W.),  70 

Thalmann,  63,  66,  71 

Thayer,  418,  419,  421,  422,  436,  444,  449, 

450,  452 
Theilhaber  (A.),  248,  331,  364 
Theole,  477 
Thevenot  (L.),  419 
Thiry,  30 

Thomas  (B.  A.),  494 
Thomin,  404 
Tic,  424 

Tobler  (M.),  309 
Tode,  26 
Tollemer,  433 


INDEX    OF    XAMES 


509 


Topfer,  232 

Tophy,  133 

Tornamira  (J.  de),  22 

Torrey  (J.  C),  74,  75,  81,  491,  492 

Toth,  316 

Trenw-ith  (W.  D.),  382,  384 

Treub,  301 

Treupel,  432 

Turk  (R.  C),  286 

Turner,  24 

Turretta  (S.),  297 

Tuttle,  488 

Tweedy,  241 

Tyler-Smitli  (W.),  25 

Tyree.  438 

T>rreII,  409 


Uffreduzzi,  287,  450 
Ulmann,.175,  420,  434 
Unna,  54,  102 
Unterberg,  452,  458 
Uysing,  418,  455 


Valentine  (F.  C),  124 

\';iii  Derbergh,  57 

Van  Gieson,  185 

Van  Oordt,  279 

Vance,  328 

Vandergrift  (G.  W.),  416 

Vanned  (T.),  81 

Vannon,  63,  71 

Vareguana  (0.),  22 

Variot,  356 

Veit,  17,  91,  99,  273,  353,  404 

Verni6,  353 

Vertes  (O.),  304 

Vetch,  24,  30 

Vidal  (E.),  442,  445,  447 

Villcmin,  317 

Viiieberg  (H.  M.),  257 

Vines  (S.),  400 

Vogel,  369 

Voight,  353 

Voillemicr,  29 

Voltorta  (F.),  289 

Von  Ammon,  404 

Von  Behring,  4s2 

\'on  de  Velde  (T.  H.),  85,  491 

\iiii  fenian,  481 

\<Mi  FniiKiuc,  229,  252,  4S4 

\nn  ll.Mkcr,  409 

\  nn  IIcilT,  313,  348,  481 


\'on  Hoffman,  424 

\'on  Leyden,  437 

\'on  Lingelsheim,  78,  79 

\'on  Xutthaft,  124 

\'<)n  Prcuscheu,  94 

\'on  Rosthorn,  106,  214.  302 

\'on  Tophy,  133 

\'an  Toth,  316 


Wachholz,  58 

Wade  (E.  M.),  485 

Waelsch,  461 

Wagner,  228,  250,  382,  461 

Waldo,  343,  353 

Walker,  471 

Walker  (H.),  478,  483 

Walthard,  107,  215 

Walton  (H.),  25 

Ward  (F.  N.),  353 

Ware,  429 

Ware  (J.),  25 

Ware  (M.  F.),  463,  466 

Warnek,  354,  355 

Wassermann,  66,  74 

Watabiki  (T.),  81 

Watkins,  301 

Watkins  (T.  J.),  279 

Watson,  228,  229 

Watson  (A.),  25 

Watson  (D.),  200 

Watson  (T.),  25 

Watson  (T.  J.),  296 

Watts  (S.  H.),  434 

Webster,  197,  239,  249 

Webster  (J.  C),  311,  330,  372 

Wegelius,  369 

Weiner  (E.),  397 

Weiner  (S.),  92 

Weinrich,  57 

Weinstein,  489 

Weir,  354 

Weis,  36 

Weiss,  427 

.Weiss  (L.),  130 

Weisswange  (F.),  455,  460 

Weitz,  419,  423 

Welandcr,  39,  202,  205,  206,  223,  468 

Wells  (J.  S.I,  25 

Welt-Kakels  (S.),  376,  385,  387 

Wendt,  41 

Wertheim,  42.  64,  72,  74,  SO,  lOli,  118, 

261,  3.-16,  390,  465 
Wp.st,  2S,  4()S 


510 


INDEX    OF    NAMES 


White,  357 

Whitehead  (J.),  25 

Widmark,  40,  404,  420 

Widnmrk  (J.),  407,  408 

Wiener  (S.),  202 

Wilcot,  326 

Wildbolz,  63,  74,  476 

Wilde,  378 

Wile  (J.  S.),  85 

Williams,  78 

Williams  (A.  W.),  442 

Williams  (J.  T.),  479 

Williams  (J.  W.),  214,  366,  369,  372,  487 

Williams  (T.  B.),  279 

Williams  (W.),  447 

Williamson,  354 

Wilson,  25,  26,  179 

Wilson  (J.  C),  432 

Winter,  231 

Wintersteiner,  405 

Winthrop,  434 

Wishart  (J.),  25 

Witherspoon  (J.  A.),  428 

Wadimirsky,  461 

Wolbarst,  378 

Wolbast,  145 

Wolff  (A.),  110 

Wolfrum  (M.  C),  406 

Wollstein,  81 

Wood  (C.  S.),  326 

Wood  (M.),  24 


Woods  (R.  F.),  377 

Woolcombe,  354 

Wordsworth  (J.  C),  404 

Wormser  (L.),  76 

Wossidle,  124 

Wright,  409,  442,  448,  486 

Wurdemann,  404 

Wylie  (L.  A.),  471,  474,  481 

Wynn,  47,  419 

Wynn  (W.  H.),  449,  460,  406,  467 

W^ssokowich,  39 


Young,  329,  466,  467 

Young  (E.  B.),  279,  479 

Young  (H.  H.),  38,  70,  390,  391,  429,  431, 

461,  466,  467 
Young  (J.),  109 


Zacharias  (P.),  297 

Zatvornitski,  408 

Zeissl,  30 

Zesas,  439,  440 

Zieler  (K.),  180,  419,  423,  424,  431,  432 

Zieler  (R.),  421 

Zinsser  (H.),  79 

Zobel  (A.  J.),  398 

Zweifel,  39,  85,  106,  283,  404,  407,  480,  484 

Zwow  (J.),  367 


INDEX 


Abscess,  articular,  425 
Bartholin's  gland,  204 
Fallopian  tube.     Sec  Pelvic  inflammatory 

disease. 
intramural,  465 
myocardial,  437 

ovarian.     See  Pchnc  inflaitinialory  disease. 
parotid  gland,  465 
perinephritis,  461 
renal,  452 
subcutaneous,  465 
suburethral.     See  Urethritis. 
uterine,  intramural,  252 
Actinomycosis,  differential  diagnosis,  271 
Adenitis,  394 

inguinal,  in  children.  384 
Adnexitis,  250 
acute,  263 

prognosis,  265 
sj'mptoms,  264 
treatment,  274 
age  of  operation  in,  388 
and  gonorrhea,  127 
cause  of  chronicity,  88 
chronic,  diagnosis,  260 
disability  from,  2(57 
examination  for,  pelvic,  268 
-pain  in,  266 
prognosis,  272 
symptoms,  265 
conservative  ovarian  surgery,  287 
surgery  in,  303 

ectopic  pregnancy  following,  303 
mortahty  attending,  302 
of  the  I'allopian  tubes,  285 
of  the  uterus  and  appendages  in,  2.S5 
pregnancies  following,  303 
secondary  operations  following,  307 
drainage  in,  314 
dysmenorrhea  in,  267 
etiology,  259 

frequency  of  gonococcal  origin,  127,  261 
herniated  inflamed  adnexa,  364 
partial  oophorectomy  in,  205 
pathology,  259 

persistence  of  gonoeocci    in    adnexal    le- 
sioas,  263 


Adnexitis,  post-operative  care  in,  318 
rupture  of  inflamed  adnexa,  310 
catises,  310 
diagnosis,  322 
prognosis,  324 
results,  320 
symptoms,  321 
table  of  cases,  326 
treatment,  325 
salpingectomy,  ovarian  conservation,  and 
suspension  of  uterus,  290 
technic  of,  203 
serum  and  vaccine  in,  491 
time  to  operate  on  cases  of,  284 
torsion  of  inflamed  adnexa,  330 
abstract  of  cases,  345 

non-gonococcal,  354 
causes,  predisposing,  342 
diagnosis,  344 
direction  of  rotation,  341 
etiology,  344 
frequency,  330 
lesions,  340 
symptoms,  343 
treatment,  345 
treatment,  274 
Bier's,  278 
cold  in,  275 
conclusions,  308 

curettage  and  iodinization,  300,  309 
drainage,  314 

end-results  of  conservative  surgery,  303 
eradication  of  infection  in  lower  genital 
tract  after  intraperitoneal  operations, 
318 
fate  of  cervix  after  supravaginal  hys- 
terectomy, 313 
heat,  with,  275 

hysterectomy    and    bilateral    salpingo- 
oophorectomy  for,  3 1 1 
mortality  of,  313 
results,  314 
mortality  of  coaservative  surgery,  302 
organotherapy  for  artificial  menopau.se, 

316 
ovarian    <'onservalii)n    after    hysterec- 
tomy, 209 
11 


512 


Adnexitis,  treatment,  palliative,  274 
results,  280 
partial  oophorectomy,  295 
post-operative  care  in,  318 
preoperative,  282 
advantages,  282 
results  of  non-operative,  280 

table  of  cases,  310 
uterine  conservation,  300 
types  of,  260 

vermiform    appendix    in,    condition    of, 
301 
Age  of  consent,  141 
Aged,  gonorrhea  in,  387 
Alcohol,  483 

experimental  efficiency,  474 
Antigonococcic  serum,  492 

administration,  technic  of,  492 
dosage,  492 
preparation  of,  491 
reaction  to,  492 
Aortitis,  439 

differential 


liagnosis,    270, 


Appendicitii 

271 
Argyrol,  480 
Arthritis,  425 

and  skin  lesions,  447 

causes,  predisposing,  425 

diagnosis,  430 

etiology,  425 

frequency,  428 

in  children  and  infants,  3S4,  427 

joints  affected,  427 

prognosis,  430 

serum  and  vaccine  in,  489 

symptoms,  428 

treatment,  431 

varieties,  428 
Artificial  menopause,  316 
organotherapy  for,  316 
results  of,  287 


Bacteremia,  418 
Bacteriology,  75 
agglutination,  75 
animal  experimentation,  7:i 
appearance  of  colonies,  71 
hacteriologic  diagnosis  of  gonorrhea,  79 
properties     of     micrococci     likely     to 
he    confused   vnth    the    gonococcus, 
60,  75 
biology,  61 


Bacteriology,  complement-fixation  test,  80, 

81 
cidture-medium,  02 

Abel's  blood-smeared  agar,  65 

Baer's,  68 

Bowhill's,  68 

Bunim's  solidified  human  blood-serum, 
63 

Duval's,  69 

Heiman's  chest  serum,  68 

Keifer's  ascitic  agar,  65 

Lipschiitz's  egg-albiunen  agar,  67 

Martin's,  68 

Naka-Abe's,  66 

reaction  of,  71 

Thalhimer's,  70 

Thalmann's,  66 

Wassermann's  nutrose,  66 

Wertheim's   human    blool-serum   and 
agar  mixture,  64 

Wright's  modification   of   SteirLschnei- 
der's  method,  65 

Young's,  70 
demonstration  of  gonococci  in  dried  secre- 
tion, 58 
diagnostic  vaccination,  84,  491 
dimensions  of  the  gonococcus,  45 
examination  of  urine  for  gonococci,  59 
Gram-negative  microorganisms,  60,  86 

-positive  microorganisms,  60 
identification  of  the  gonococcus  by  stains, 

55 
immunity,  75 
Meningococcus  or  Diplococcus  intracellu- 

laris  meningitidis,  77 
method  of  reduplication,  44,  45 

of  testing  colonies,  73 
Micrococcus  catarrhalis,  78 
mixed  infectioiLs,  85 
morphology,  44 
motility,  45 
organisms  likely  to  be  mistaken  for  the 

gonococcus,  60,  75 
relation  of  the  numbei  and  morphology  of 

the  gonococci  to  the  stage  and  virulence 

of  the  disease,  45 
resistance,  62 

staining  properties  of  the  gonococcus,  49 
stains  for  gonococci,  44 
Abbott's,  51 
Giemsa's,  53 
Gram's,  55 

for  sections,  56 
Knaack's,  53 


513 


Bacteriologj",  stains  for  gonococci,  Lanz's, 
54 
Leishman's  modification  of  Roman- 

owsky's,  52 
Leszczynsky's,  53 
Loffler's  methylene-blue,  50 
modification  of  Gram's,  57 
Neisser's  double  stain,  50 
Pappenheim's,  51 
Sax's  modification  of  Romanowsky's, 

52 
Unna-Pappenheim's,  for  sections,  54 
toxins,  74 
Bartholinitis,  93.  201 
etiology,  91 
frequency,  202 
in  children,  3S4 
treatment,  203 
Bartholin's  gland,  abscess,  93,  204 
histology,  93 
symptoms,  204 
treatment,  205 
anatomic  structure  of,  90,  201 
cyst,  91,  203 
diagnosis,  203 
histology,  92 
symptoms,  203 
treatment,  203 
Bier's  treatment  of  pelN'ic  inflammatory  dis- 
ease, 278 
Birth-weight  of  infants  of  gonorrheal  moth- 
ers, 128 
Blindness  due  to  gonorrhea,  128 
Bone  and  joint  lesions,  425 
Boric  acid,  485 
Bullous  eruption,  445 


Carcinoma,   gonorrhea   as   a   predisposing 

factor  in  the  production  of,  363 
Cellulitis,  non-pelvic,  407 
Cervicitis,  222 
acute,  223 
symptoms,  223 
treatment,  226 
chronic,  223 
symptoms,  223 
treatment,  226 
diagnosis,  225 
fretiuency,  96,  223 
histology,  97 
pathology,  90 
scrum  and  vaccine  in,  490 

33 


Children,  gonorrhea  in,  376 
Chondritis,  435 
Choroiditis,  416 

Chronicity  often  due   to  reinfection  from 
•     husband,  194 
Cold  in  treatment  of  pelvic  inflammatory 

disease,  275 
CoUargol,  484 
Condition  of  vermiform  appendix  in  pelvic 

inflammatory  disease,  301 
Condylomata  acuminata,  198 
diagnosis,  199 
etiology,  199 
histologj',  94 
in  children,  384 
pathology,  93 
symptoms,  198 
treatment,  199 

when  complicated  by  pregnancy,  201 
of  cervix,  231 
of  vagina,  217,  222 
ConjunctiWtis,  490 
in  adults,  413 
symptoms,  413 
treatment,  414 
in  young  girls,  413 
metastatic,  414 
diagnosis,  415 
symptoms,  415 
treatment,  416 
serum  and  vaccines  in,  490 
Conservative  ovarian  surgery,  287 
surgery,  303 

of  the  Fallopian  tubes,  285 
results  of,  in  pelvic  inflammatory  dis- 
ease, 303 
Cost  of  gonorrhea  to  the  State,  128 

of  venereal  disease,  151 
Curettage  and  iodiiiization,  309 

as   preliminary    step    in    intraperitoneal 

operations,  309 
in  treatment  of  pelvic  inflammatory  dis- 
ease, 300 
Cutaneous  lesions,  442 
Cyst  of  Bartholin's  gland,  91.  203 
diagnosis,  203 
histology,  92 
symptoms,  203 
of  vulvovaginal  gland,  203 
Cystitis,  390 

and  MiixcMJ  infection,  390 
fre<|ncncy,  390 
in  children,  3S4 
mode  of  infection,  390 


514 


Cj'stitis,  symptoms,  391 
treatment,  393 


Deciduitis,  366 

Demonstration  of  gonococci  in  discharge,  47 
acute  stage,  47 
chronic  stage,  48 
Diagnosis  of  gonorrhea,  79 
bacteriologic,  79 
complement-fixation  test,  80 
diagnostic  vaccination,  84,  491 
leukocytes  in  gonorrhea,  85 
DisabiUty  in  chronic   pehic  inflammatory 

disease,  267 
Discharge,  46 
character  of,  46 
acute  stage,  46 
chronic  stage,  46 
terminal  stage,  46 
demonstration  of  gonococci  in,  47 
methods   to   facilitate   demonstration   of 
gonococci  in,  48 
Drainage  in  pelvic  inflammatory  disease,  314 
Dysmenorrhea  in  chronic  pelvic  inflamma- 
tory disease,  267 


Ear,  gonorrhea  of,  465 
Ectopic  pregnancy   caused   by   salpingitis, 
263 
differential  diagnosis,  269 
following  conservative  surgery  in  pel- 
vic inflammatory  disease,  307 
Elephantiasis  and  gonorrhea,  364 
Endocarditis,  436 

causes,  predisposing,  437 
diagnosis,  438 
frequency,  436 
pathology  of,  437 
prognosis,  438 
sj'mptoms,  438 
treatment,  438 
valves  affected,  436 
Endocervicitis,  97 
histology,  97 
pathology,  97 
Endometritis,  232 
acute,  236 
diagnosis,  236 
symptoms,  234 
treatment,  236 
and  adenomyoma  uteri,  245 
chronic,  238 


Endometritis,  chronic,  diagnosis,  238 
histology,  103 
symptoms,  237 
treatment,  239 
corporeal,  99 
frequency,  233 
histologic  varieties,  99 
menstrual  changes  in,  100 
pathology,  98 
plasma  cells  in,  99 
report  of  cases,  246 
Eruptions,  442 
Erythema  nodosum,  444 

simple,  444 
Esthiomene  and  gonorrhea,  364 
Examination  of  patients,  183 
anamnesis,  183 
anesthesia,  193 
asepsis  in,  190 
bacteriologic,  193 
by  rectum,  193 

dorsal  or  Uthotomy  position,  187 
examining  table,  184 
in  bed,  192 

instruments,  lubricants,  etc.,  185 
knee-chest  position,  191 
method   of   deaUng   with  female   gon- 

orrheics,  194 
of  performing,  188 
palpation,  192 
preparation  for,  183 
securing     material     for      bacteriologic 

study,  188 
Sims'  left  lateral  position,  191 


Factors  governing  infection,  120 
Fate  of  cervix  after  supravaginal  hysterec- 
tomy, 313 
Formaldehyd,  experimental   efficiency,  474 
FormaUn,  484 

Fowler's  position  in  treatment  of  pelvic  in- 
flammatory disease,  276 
Frequency  of  gonorrhea,  128 
among  civilians,  129 
in  armies  of  world,  133,  138 
in  navies  of  world,  138 
in  pregnancy,  366 
in  United  States  Army,  134,  136 
Navy,  135,  137 


Gingivitis,  400 
Gonoblennorrhea,  402 


515 


Gonococcide,  requirements  of,  470 
Gonococcus,  362 
agglutination,  75 
animal  experimentation,  73 
appearance  of  colonies,  71 
as  the  cause  of  diffuse  peritonitis,  355 
persistence  in  tubes,  88 
puerperal  infection,  368 
bacteriologic  properties  of  microorganisms 

likely  to  be  confused  with,  60,  75 
biology,  61 
culture-medium,  62 

Abel's  blood-smeared  agar,  65 
Baer's,  68 
Bowhill's,  68 

Bumm's  solidified  human  blood-ser- 
um, 63 
Duval's  medium,  69 
Heimau's  chest  serum,  68 
Keifer's  ascitic  agar,  65 
Lipschiitz's  egg-albumen  agar,  67 
Martin's,  68 
Naka-Abe's,  66 
reaction  of,  71 
Thalhimer's,  70 
Thalmann's,  66 
Wassermann's  nutrose,  66 
Wertheim's  human  blood-serum  and 

agar  mixture,  64 
Wright's  modification  of  Steinschnei- 

der's  method.  65 
Young's  medium,  70 
demonstration  during  acute  stage,  47 
during  chronic  stage,  48 
of  gonocooci  in  dried  secretion,  .58 
dimensions  of,  45 
discovery  of,  35 
frequency  in  pregnancy,  366 
firam-negative  microorganisms,  60,  86 
identification  of,  by  stains,  55 
inmiunity  to,  75 
in  the  decidua,  366 

location  from  which  to  obtain  .secretion,  47 
method  of  reduplication,  44 

of  testing  colonics,  73 
methods  to  facilitate  the  ilemonstration 

of,  48 
mixed  infections,  85 
morphology,  44 
motility,  45 

organisms  likely  to  be  mistaken  for,  60,  86 
period  of  incubation,  118 
persistence  in,  of  adnexal  lesions,  263 
in  the  female  genitalia,  124 


Gonococcus,  persistence  in,  in  lower  genital 
tract  as  a  cause  for  failure  in  oper- 
ative cases,  318 

in  the  prostate,  124 

in  vulvovaginitis  of  childhood,  383 
relation   of  number  and   morphology  of 

gonococci  to  stage  and  virulence  of  dis- 
ease, 45 
resistance,  62 

secretion,  examination  of,  193 
staining  properties  of,  49 
stains  for,  49 

Abbott's,  51 

Giemsa's,  53 

Gram's,  55 
for  sections,  56 
modification  of,  57 

Knaack's,  53 

Lanz's,  64 

Leishman's    modification    of    Roman- 
owsky's,  52 

Leszczynsky's,  53 

Loffler's  methylene-blue,  50 

Neisser's  double,  50 

Pappenheim's,  51 

Sax's  modification  of  Romanowsky's,  52 

Unna-Pappenheim's,  for  sections,  54 
toxins,  74 

urine,  examination  of,  59 
virulence  of  different  strains,  119 
vulvovaginitis  of  childhood,  376 


Heat  in  treatment  of  pelvic  inflammatory 

disease,  275 
Hemorrhagic  eruption,  445 
Herniated  inflammatory  adnexa,  364 
Historic,  17 

among  the  early  Arabians,  21 

among  the  early  .Japanese,  17 

among  the  early  Romaas,  18 

among  the  early  Syrians,  17 

among  the  Greeks,  20 

biblical  references  to  gonorrhea,  20 

derivation  of  term  gonorrhea,  17 

discovery  of  the  gonococcus,  35 
of  pseu<lo-gotiococci,  41 

experiments  with  the  gonococcus,  39 

gonorrhea  and  ophthalmia,  24,  39 

Hunter's  experiment,  26 

in  the  fourteenth  century,  21 

in  the  Middle  Ages,  21 

in  the  sixteenth  century,  23 

Noeggerath's  observations,  28,  32 


516 


Historic,  Ricord's  observations,  28 
sjiionyms  for  gonorrhea,  17 
virulists  and  antivirulists,  30 
Hydrops  tubae  profluens,  360 
etiology,  361 
pathology,  113 
symptoms,  361 
Hydrosalpinx,  113 
histology,  113 
intermittent,  360 
etiology,  361 
pathology,  113 
symptoms,  361 
pathology,  111 
Hyperkeratosis,  445 

Hysterectomy  and  bilateral  salpingo-ociphor- 
ectomy  for  peh-io  inflamma- 
tory disease,  312 
mortaUty  of,  313 
results,  314 


ICHTHYOL,  485 

Incubation,  period  of,  118 
Infection,  121 

factors  governing,  121 

method  of,  in  adults,  117 
in  children,  377 

pathogenesis  of,  117 

source  of,  139,  140,  141 
Intramural  abscess,  465 
Intrapehic  neoplasms,  infection  of,  361 
lodin,  482 

experimental  eflBciency  of,  473 

serum  and  vaccine  in,  490 
Iridocychtis,  416 
Iritis,  416 


Keratitis,  416 

K^ratodermie  blennorrhagique,  445 
Kidney,  gonorrhea  of,  452 
diagnosis,  456 
further  literature,  460 
mixed  infections,  452 
modes  of  infection,  453 
prognosis,  456 

■  pyeUtis,  abstracts  of  recorded  cases  of, 
457 
pyelonephritis,    abstracts   of   recorded 

cases  of,  458 
symptoms,  455 
treatment,  456 


Latent  gonorrhea,  120 

Leukocytes  in  gonorrhea,  85 

Location  from  which  to  obtain  secretion  in 

suspected  cases,  47 
Lung,  gonorrhea  of,  449 
Lymphadenitis,  394 
Lysol,  485 


Meningococcus  or  Diplococcus  intracellu- 

laris  meningitidis,  77 
Menstrual   disturbances  in  chronic   pelvic 

inflammatory  disease,  265 
Mercury  solutions,  experimental  efficiency, 

472 
Method  of  securing  material  for  bacterio- 

logic  examination,  188 
Methods  to  facilitate  the  demonstration  of 

the  gonococcus,  48 
Metritis,  246 
acute,  246 
diagnosis,  247 
symptoms,  247 
treatment,  248 
chronic,  248 
s3Tnptoms,  248 
treatment,  249 
histology,  104 
pathology,  104 
Micrococcus  catarrhalis,  78 
Mixed  infections,  85,  362,  368 

cause  of  prolongation  of  symptoms,  88 
conservative  sui-gery  in  pehnc  inflam- 
matory disease,  302 
in  pregnancy,  368 
MortaUty  due  to  gonorrhea,  126 
Motor  gastric  insufficiency  caused  by  gon- 
orrheal adhesions,  358 
Myocarditis,  439 
Myositis,  suppurative,  465 


Nasal  gonorrhea,  401 
Necessity  of  curing  husband  as  well  as  pa- 
tient, 194 
Neoplasms,  differential  diagnosis,  269 
Nephritis,  452 
Nervous  system,  461 

gonorrhea  of,  461 

neuritis  and  neuralgia,  462 

neuroses,  463 
Neuralgia,  462 
Neuritis,  462 


517 


Neuroretinitis,  416 
Neuroses,  463 


Oophoritis,  pathology  of,  115 
Ophthalmia  in  children,  3S5 
neonatorum,  407 

blindness  due  to,  407 
complications,  405 
cost  to  government,  403 
diagnosis,  408 
etiology,  128,  402 
frequency,  402 
incubation  of,  405 
notification  in,  410 
predisposing  causes  of,  407 
symptoms,  405 
systemic  complications,  408 
treatment,  411 
curative,  411 
prophylactic,  409 
technic  of,  410 
varieties,  404 
Ophthalmoblennorrhea,  402 
Organotherapy  for  artificial  menopause,  316 
Osteoperiostitis,  433 
symptoms,  434 
treatment,  435 
Otitis,  465 

Ovarian  abscess.     See  Pelvic  inflammalory 
disease. 
pathology  of,  115 
blood-supply,  291 

conservation  after  hysterectomy,  299 
Ovary,  frequency  of  various  lesions  in,  114 


Pain  in  pehic  inflammatory  disease,  270 
Palliative  treatment  of  pelvic  inflammatory 
disease,  274 
results,  280 
Parotiditis,  465 
Partial  oophorectomy  in  pehic  iiiHamma- 

torj'  disease,  295 
Pathology,  93 
abscess  of  Bartholin's  gland,  93 
adnexal  lesions,  frequency  of,  105 
bartholinitis,  93 
cervicitis,  9() 

condylomata  acuminata,  93 
corporeal  endometritis,  98 

menstrual  changes  in,  100 
significance  of  plasma  cells,  99 
varieties,  99 


Pathologj',  cj-st  of  Bartholin's  gland,  91 
endocervicitis,  97 
endometritis,  103 
general  consideration,  87 
hydrops  tubae  profluens,  113 
hydrosalpinx,  111 

intermittent,  113 
metritis,  104 
oophoritis,  115 
ovarian  abscess,  115 

ovary,  frequency  of  various  lesions  in,  114 
pathology,  109 
peri-oophoritis,  114 

bearing  upon  ovarian  conservation,  114 
plasma  cells,  102 

description  of,  102 
staining,  101 
pyosalpinx,  109 
salpingitis,  107 

tubal  lesions,  characteristic,  105 
tubo-ovarian  abscess,  116 

cyst,  116 
urethritis,  95 
vaginitis,  94 
vulvitis,  90 
Pelvic  inflammatory  disease,  263 
acute,  263 
prognosis,  265 
symptoms,  264 
treatment,  274 
age  of  operation  in,  388 
cause  of  chronicity,  88 
chronic,  269 

diagnosis,  269  , 

difficulties  of,  272 
disability,  267 
examination  of,  pelvic,  268 
pain  in,  "266 
prognosis,  272 
symptoms,  265 
conservative  ovarian  surgery,  287 
surgery  in,  303 

ectopic  pregnancy  following,  303 
mortality  attending,  302 
of  the  Fallopian  tubes,  285 
of  the  uterus  and  appendages  in, 

285 
pregnancies  following,  .303 
secondary  operations  follow-ing, 
307 
drainage  in,  314 
dysmenorrhea  in,  267 
etiology,  1'27,  '261,  259 
freciucncy  of,  105,  '259 


518 


Pelvic  inflammatory  disease,  frequency   of 
gonococcal  origin  of,  261 
herniated  inflamed  adnexa,  364 
partial  oophorectomy  in,  295 
pathology,  259 
persistence  of  gonococci  in  adnexal 

lesions,  263 
post-operative  care  in,  318 
rupture  of  inflamed  adnexa,  319 
causes,  319 
diagnosis,  322 
prognosis,  324 
results,  320 
symptoms,  321 
table  of  cases,  326 
treatment,  325 
salpingectomy,  ovarian  conservation 
and   suspension   of   uterus, 
290 
technic  of,  293 
serum  and  vaccine  in,  491 
time  to  operate  on  cases  of,  284 
torsion  of  inflamed  adnexa,  339 
abstract  of  cases,  345 

non-gonococcal,  345 
causes,  predisposing,  342 
diagnosis,  344 
direction  of  rotation,  341 
etiology,  344 
frequency,  339 
lesions,  340 
symptoms,  343 
treatment,  345 
treatment,  274 
Bier's,  278 
cold,  275 
conclusions,  308 
curetage    and    iodinization,     300, 

309 
drainage,  314 
end  results  of  conservative  surgery, 

303 
eradication  of  infection  in  lower 
genital  tract  after  intraperitoneal 
operations,  318 
fate  of  cervix  after  supravaginal 

hysterectomy,  313 
heat,  275 

hysterectomy    and    bilateral    sal- 
pingo-oophorectomy  for,  311 
mortality  of,  313 
results,  314 
mortality  of  conservative  surgery, 
302 


Pelvic    inflammatory    disease,     treatment, 
organotherapy      for       artificial 
menopause,  316 
ovarian  conservation  after  hyster- 
ectomy, 299 
palliative  treatment,  274 

results,  280 
partial  oophorectomy,  295 
post-operative  care  in,  318 
preoperative  care,  282 

advantages,  282 
results  of  non-operative,  280 

table  of  cases,  310 
uterine  conservation,  300 
types  of,  260 

vermiform  appendix  in,  condition  of, 
301 
Pericarditis,  438 
Perichondritis,  435 
Perinephritis,  461 
Perioophoritis,  114 
pathology,  114 

bearing  upon  ovarian  conservation,  114 
Periostitis,  433 
Peritonitis,  diffuse,  355 
diagnosis,  359 
etiology,  356 
frequency,  356 
report  of  cases,  358 
symptoms,  357 
treatment,  359 
in  children,  386 
diagnosis,  386 
frequency,  385 
symptoms,  386 
treatment,  387 
Persistence  of  gonorrhea,  123 

necessity  of  curing  husband,  194 
Phenol,  485 

experimental  efficiency,  473 
Phlebitis,  439 
Picric  acid,  484 
Plasma  cells,  102 

description  of,  102 
in  corporeal  endometritis,  99 
staining,  101 
Pleurisy,  450 

abstracts  of  recorded  cases,  451 
Post-operative  care  in  pelvic  inflammatory 

disease,  318 
Pregnancy  and  gonorrhea,  366 
diagnosis  of  infection,  368 
frequency,  366 
symptoms  of  infection,  367 


519 


Pregnancy  and  gonorrhea,  treatment  of  in- 
fection, 368 
Proctitis,  395 

frequency,  395 

in  children,  385 

symptoms,  396 

treatment,  397 
Prophylaxis,  141 

age  of  consent,  141 

alcohol  and  venereal  disease,  146 

all  patients  should  be  entirely  cured  be- 
fore discharged,  170 

as  practised  in  the  na\-j',  174 

educational,  141 

ethical  duty  of   physician    toward    gon- 
orrheics,  172 

general,  141 

in  gonorrhea  of  lower  genital  tract,  198 

legal,  regarding  ophthalmia  neonatorum, 
168 

marriage  and  gonorrhea,  171 

method  of  dealing  with  gonorrheics  to 
prevent  spread  of  the  disease,  164 

national  organization  for,  145 

need  of  hospital  facilities,  164 

pamphlets  for  all  venereal  patients,  "165 

personal,  172 

registration  of  venereal  patients,  1G9 

results  of  navy  prophj'laxis,  175 
Prostitution,  149 

antiquity,  149 

argument  agaiiwt,  161 

arguments  for  regulation  of,  158 

as  source  of  infection,  139 

attempts  to  eradicate,  149,  1.52 

conclusions  regartiing,  162 

frequency  of  gonorrhea  in  prostitutes,  150 

in  Austro-Ilungary,  157 

in  England,  1.56 

in  France,  156 

in  Germany,  1.52 

in  Holland  and  Denmark,  1.56 

in  Italy,  1.5f) 

in  Japan,  156 

in  Norway,  155 

in  Sweden  and  FinlancI,  1.55 

in  United  States,  157 
Protargol,  481 
Pruritus  vulvar,  230 
Pseudo-gotiococci,  discovery  of,  41 
Puerperal  infection,  373 
diagno.sis,  371 

frequency  of  gonococcus  in,  368 
prognosis,  372 


Puerperal  infection,  symptoms,  369 
treatment,  373 
curative,  373 
indications    for   operation    in    acute 

stage,  375 
prophylactic,  372 
Pyosalpinx,  88 

cause  of  chronicity,  88 
histology,  110 


Racial  susceptibility,  125 
Radium  in  treatment  of  pelvic  inflamma- 
tory disease,  277 
Reinfection  from  husband,  194 
Results  of  conservative  surgery  in  pelvic  in- 
flammatory disease,  303 
Rhinitis,  401 
Rupture  of  inflamed  adnexa,  319 

causes,  319 

diagnosis,  321 

prognosis,  324 

results,  320 

symptoms  of,  321 

table  of  cases,  326 

treatment,  325 


Salpingectomy,  285 

condition  of  ovary,  290 

ovarian  conservation  and  suspension  of 
uterus,  290 

technic  of,  293 
Salpingitis,  88 

cause  of  chronicity,  88 

histology,  108 

pathology,  107 
Secondary  operation  following  conservative 

surgery  in  pelvic  inflammatory  disease, 

307 
Septicemia  and  skin  lesions,  444 

bacteremia  and  toxemia,  418 

cau.ses,  predisposing,  419 

diagnosis,  424 

etiology  of,  418 

frequency,  419 

serum  and  vaccines  in,  IS7 

symptoms,  422 

treatment,  424 
Serum  and  vaccine  therapy,  4S() 
arthritis,  4.S9 
genital  gonorrhea,  490 
in  conjunctivitis,  490 
inilicatioiLs  for,  486 


520 


Serum  and  vaccine  therapy  in  septicemia, 
487 
iritis,  490 
skin  lesions,  488 
vaginitis  in  children,  488 
Silver  acetate,  480 
nitrate,  479 

salts,  experimental  efficiency,  472 
vitellin,  470 
Skenitis,  207 
Skin  lesions,  442 

bullous  or  hemorrhagic,  445 
causes,  predisposing,  443 
diagnosis,  449 
erythema,  simple,  444 
etiology,  443 
hyperkeratosis,  445 
literature,  442 
serum  and  vaccines  in,  488 
treatment,  449 
ulcers,  448 

urticaria  or  erythema  nodosum,  444 
varieties,  444 
Source  of  infection,  139 
Spondylitis  deformans,  431 
SteriUty  and  gonorrhea,  127,  366 
Stomatitis,  401 
diagnosis,  401 
frequency,  398 
symptoms,  399 
treatment,  401 
Streptococcic   infections,   differential   diag- 
nosis, 271 
Stricture  of  urethra,  211 
symptoms,  211 
treatment,  212 
Subcutaneous  abscess,  465 
Suburethral  abscess,  207 
Susceptibility,  racial,  125 


Tenonitis  in  children,  385 
Tenosynovitis,  433 
Therapy,  469 
alcohol,  483 
argyrol,  480 
boric-acid,  485 
collargol,  484 
corrosive  sublimate,  481 
experimental  efficiency,  470 
alcohol,  474 
forraaldehyd,  474 
iodin,  473 
mercury  solutions,  472 


Therapy,   experimental  efficiency,  phenols, 
473 
silver  salts,  472 
testing,  method  of,  470,  474 
formalin,  484 

gonococcides,  requirements  of,  470 
ichthyol,  485 
iodin,  482 
lysol,  485 
phenol,  485 
picric  acid,  484 
protargol,  481 
silver  acetate,  480 
nitrate,  479 
Thrombosis,  441 

Time  to  operate  on  cases  of  pelvic  inflamma- 
tory disease,  284 
Torsion  of  inflamed  adnexa,  339 
abstract  of  cases,  345 

non-gonococcal,  354 
causes,  predisposing,  342 
diagnosis,  344 
direction  of,  341 
etiology,  340 
frequency,  339 
lesions,  340 
symptoms,  343 
treatment,  345 
Toxemia,  418 

Tubal  lesions,  pathologic  characteristics  of, 
105 
pregnancy,  differential  diagnosis,  269 
salpingitis  as  a  cause  of,  363 
Tuberculous  salpingitis,  differential  diagno- 
sis, 269 
Tubo-ovarian  abscess,  pathology  of,  116 
cyst,  pathology  of,  116 


Ulcers  of  skin,  448 
Urethra,  stricture  of,  211 
symptoms,  211 
tieatment,  212 
Urethritis,  206 
acute,  206 

symptoms,  206 
treatment,  209 
■clu-onic,  207 
symptoms,  207 
treatment,  210 
frequency,  205 
histology,  96 
pathology,  95 


serum  and  vaccines  in,  490 


521 


Urethritis,  skenitis,  207 
treatment,  211 
suburethral  abscess,  207 
Urticaria,  444 

Uterine  abscess,  intramural,  252 
diagnosis,  255 
frequency,  253 
report  of  a  case  of,  256 
aj'mptoms,  254 
treatment,  256 
conservation  in  operative  treatment  of 
pelvic  inflammatorj'  disease,  300 


Vaccixe,  493 
autogenous  and  stock,  493 
diagnostic,  84,  491 
dosage,  494 
opsonic  index,  493 
Vaginitis,  95 
acute,  216 

symptoms,  216 

treatment,  219 
bactericidal  properties  of  the  vagina,  213 
chronic,  217 

symptoms,  217 

treatment,  220 
condylomatosa,  217,  222 
diagnosis,  218 
histology,  95 
in  children,  488 
pathology,  94 

predisposing  factors  to,  215 
serum  and  vaccines  in,  488 


Venereal  warts.     See  Condylomata  acumin- 
ata. 
in  children,  384 
Vermiform   appendix,   involvement   of,    in 
chronic  peKic  inflammatory  disease,  267 
Vul\-itis,  195 
diagnosis,  196 
pathology,  90 
histology,  90 
macroscopic,  89 
symptoms,  195 
treatment,  196 
prophylactic,  198 
Vulvovaginal  gland,  90 

anatomic  structure,  201 
inflammations.     See  Bartholinitis. 
Vulvovaginitis  in  children,  380 
complications,  380,  384 
diagnosis,  381 
duration  of,  383 
epidemics  of,  376 
frequency,  376 
modes  of  infection,  377 
symptoms,  379 
treatment  of,  382 
curative,  382 
prophylactic,  381 


Wound  infection,  467 


X-RAY  in  treatment  of  pelvic  inflammatory 
disease,  278 


DATE  DUE 


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DEMCO  38-296 


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0041071735 


Forris 

Gonorrhea  in  wonen. 


RC2C2 
1913 


